Compositions and methods for tumor immunotherapy

ABSTRACT

Provided are compositions and methods for treating cancer using administration of certain volumes of CpG oligonucleotides (CpG ODN) and, optionally, administration of a checkpoint inhibitor such as an anti-PD-1 antibody, an anti-PD-L1 antibody, and/or an anti-CTLA-4 antibody. In preferred embodiments, the CpG ODN are selected based on their propensity to induce high amounts of interferon alpha (IFN-a) and T-cell activation relative to interleukin-10 (IL-10) and B-cell activation. In certain embodiments, the methods further include pretreatment with radiotherapy, to potentiate the combination immunotherapy.

INCORPORATION BY REFERENCE OF MATERIAL SUBMITTED ELECTRONICALLY

Incorporated by reference in its entirety is a computer-readablesequence listing submitted concurrently herewith and identified asfollows: Filename: 52757_Seqlisting.txt; Size: 142,708 Bytes; Created:Feb. 12, 2019.

BACKGROUND OF THE INVENTION

Many scientists have sought to treat cancer by activating the immunesystem against the tumor. However, despite occasional successes, durableresponses to immune therapy have been rare and limited to just a fewtumor types. Current understanding of cancer immunotherapy among thoseskilled in the art has been summarized in recent review articles,including for example Chen and Mellman, Immunity 2013 39(1): 1-10. Thecycle for induction of therapeutic immune responses against tumors maybe broken down into seven distinct steps: Release of cancer cellantigens; Presentation of cancer cell antigens by antigen-presentingcells (APC, usually in draining lymph nodes); T-cell priming andactivation; Trafficking of CD8⁺ T cells to tumors; Infiltration of CD8⁺T cells into tumors; Recognition of cancer cells by the infiltratingCD8⁺ T cells; and Killing of cancer cells.

The art teaches that there are multiple negative and positive mediatorsof each step of the anti-tumor response. Recent research interest hasfocused on understanding and addressing the role that negative mediatorsplay in inhibiting the anti-tumor immune response. For example,interleukin-10 (IL-10) is a factor that can have complicated effects,locally immune suppressive in the tumor, but systemically can actuallyhave anti-tumor activity (reviewed in Vicari and Trinchieri, Immunol.Rev., 2004). Although Toll-like receptor (TLR) agonists such asTLR9-activating CpG oligonucleotides (CpG ODN) have immune stimulatoryeffects that can promote anti-tumor responses, they are also known inthe art to induce immune suppressive factors such as IL-10 (reviewed inLu, Frontiers Immunol, 2014). The art does not teach designs of TLR9agonists that have improved anti-tumor effects as a result of inducinglower amounts of IL-10 production. Nevertheless, this increasing recentunderstanding of the cycle of tumor immunity has heightened awarenessthat it may be possible to increase the clinical efficacy of cancerimmunotherapy by using combinations of agents that act at differentpoints in this cycle for induction of therapeutic immune responsesagainst tumors, but the art does not provide a deep enough understandingof the immunobiology of cancer to predict which of the many differentpossible combinations will be preferred.

Another possible way to consider the development of the anti-cancerT-cell response is the 3-signal model for the induction of a T-cellresponse, summarized by Kim and Cantor, Cancer Immunol Res 20142:929-936). In this model a signal to the T cell comes from thepresentation of antigen by an APC on the appropriate MHC to the T cellreceptor. A second signal is the requirement for a costimulatory signalthrough the interaction of CD28 on the T cell by B7-1 or B7-2 on the APC(this signal is antagonized by CTLA-4 present on Treg: the efficacy ofanti-CTLA-4 antibodies in cancer immunotherapy results from theirinhibition of this “off” signal). Finally, a third signal is themodulation of T cell function resulting from signals via inflammatorycytokine receptors and PD-1. In particular for the induction of optimalCD8⁺ T cell responses, which are known to be critical for successfulcancer immunotherapy, type I IFN signaling is a very positive signal,but when chronic or prolonged also can paradoxically lead to T cellexhaustion and unresponsiveness, which is mediated through upregulationof PD-1 expression. Blocking of PD-1 (e.g., by anti-PD-1 antibodies, orby antibodies to its major ligand regulating anti-tumor immunity, PD-L1)restores the ability of the T cell to proliferate and produce cytokinesin the tumor microenvironment.

Recently there have been several early clinical successes with the useof “checkpoint inhibitor” (CPI) compounds, such as antibodies, whichblock the negative immune effects of the checkpoint molecules such asCTLA-4, PD-1, and its ligand, PD-L1. Systemic administration ofanti-CTLA-4 antibodies has led to durable responses in ˜10% of patientswith melanoma, and some encouraging early results in other tumor types,but at the cost of a high rate of adverse effects, including death insome patients. Anti-PD-1/PD-L1 human clinical trials also have beenreporting encouraging results, apparently with a lower rate of severetoxicity. However, analyses of the responding patients have revealedthat across multiple different types of cancer, responses to anti-PD-L1therapy are relatively restricted to patients with tumor-infiltratinglymphocytes (TIL) and a Th1 pattern of gene expression in the tumor(Powles et al., Nature 2014 515:558; Herbst et al., Nature 2014 515:563;Tumeh et al., Nature 2014 515:568). That is, responses can be seen insome patients with preexisting immunity to the tumor, but are quiteunlikely to occur in patients without this. Aside from melanoma, inwhich pre-existing anti-tumor immunity is relatively common, TIL arerelatively uncommon in most other tumor types, indicating that CPI maybe of limited benefit in most types of cancer.

Thus, there is a need to improve the efficacy of for cancer therapy andfor therapies that include the use of CPI.

SUMMARY OF THE INVENTION

The present disclosure provides compositions and methods for treatingcancer. As described herein, the volume of the one or more compositionsthat are administered to a subject in need of cancer therapy is animportant consideration to maximize efficacy. In various embodiments,the volume that is administered is higher than what has previously beendescribed. (See, for example, PCT/US2015/067269 which is incorporated byreference herein in its entirety)

The present disclosure also provides compositions and methods forpromoting immune activation and reducing immune inhibition, thusmetaphorically both “stepping on the gas” and “releasing the brakes” ofthe immune system, to treat cancer. The disclosure can be used, forexample, to convert “cold” (treatment-resistant or -refractory) cancersor tumors to “hot” ones amenable to treatment, including treatment withcheckpoint inhibition.

The present disclosure provides in some embodiments specific subtypes ofCpG ODN with reduced amounts of phosphorothioate modifications comparedto the CpG ODN most widely used in past cancer immunotherapy, andmethods for their intratumoral and peritumoral administration incombination with CPI and/or radiotherapy (XRT), for the improvedimmunotherapy of cancer, including cancers that would be unlikely torespond to any of these therapies alone, or in other combinations.

CpG ODN bind and stimulate TLR9, an innate immune receptor which isconstitutively expressed in only two types of human immune cell: Bcells, which respond to TLR9 stimulation by proliferating and secretingimmunoglobulin; and plasmacytoid dendritic cells (pDC), which respond toTLR9 stimulation by secreting large amounts of type I IFN (IFN-α andIFN-β). The present disclosure is based, at least in part, on thefinding that the IFN-α response to CpG ODN is important for tumorimmunotherapy. The present disclosure is based, at least in part, on thefinding that a strong IFN-α response to CpG ODN is important for tumorimmunotherapy, including tumor immunotherapy using intratumoraladministration of CpG ODN.

Preferred CpG ODN of the disclosure are characterized, at least in part,by their propensity to induce high amounts of type I IFN.

Type I IFN is believed to play a key role in tumor rejection. Forexample, Type I IFN augments CD8+ T-cell survival, expansion, andeffector differentiation; promotes dendritic cell (DC) maturation,cross-presentation of tumor-associated antigens to CD8+ T cells; isrequired for immune surveillance against carcinogen-induced tumors; andis required for rejection of implanted tumors. Additionally, levels oftype I IFN-related mRNA correlate with tumor-infiltrating lymphocytes(TILs) in human metastases.

In addition to inducing higher levels of type I IFN than anything else,TLR9 ligands such as CpG ODN also activate pDC and induce secretion ofhundreds of other Th1-promoting genes and factors; and convert pDC fromimmature/tolerance-promoting phenotype to mature, activated, cytotoxic Tlymphocyte (CTL)-inducing phenotype.

The present disclosure also is based, at least in part, on the findingthat delivery of the CpG ODN into tumors (directly or indirectly)induces the expression of adhesion molecules in the local vasculature inand around the tumor, and promotes the egress of activated T cells (CD4⁺and CD8⁺) from capillaries into the tumor and surrounding region. Someof these T cells will be specific to the unmutated and mutatedtumor-associated antigens (TAA). In the absence of checkpoint inhibitorsand/or XRT, these T cells may be inhibited by the tumor, but incombination, this creates a much more powerful anti-tumor effect thancan be achieved with CpG or the checkpoint inhibitors or XRT on theirown.

The present disclosure in certain aspects is based on the use of CpG ODNclasses other than those that have historically been used for cancerimmunotherapy. In particular, the present disclosure in certain aspectsis based on the use of high IFN-α secreting classes, the A-class andE-class, with reduced amounts of phosphorothioate (PS) modificationscompared to B-class CpG ODN that have been widely used in the past.B-class CpG ODN are typically completely phosphorothioate-modified toincrease their resistance to nucleases and the magnitude of the B-cellactivation. In contrast, since a focus of the present disclosure is onachieving a high type I IFN response, rather than B-cell activation, thepreferred CpG ODN of the present disclosure have either nophosphorothioate modifications, or only 1 or 2 phosphorothioatemodifications at the 5′ end and 1 to 4 phosphorothioate modifications atthe 3′ end. Preferred E-class ODN of the disclosure also containphosphodiester (PO) linkages at the CpG dinucleotides, and optionally atother positions within the ODN, in order to reduce the B cell activation(and concomitant IL-10 and indoleamine 2,3-dioxygenase (IDO) induction),and they also preferably contain one or more palindromes to formduplexes or concatamers.

Those skilled in the art understand that intra- or peritumoral CpG inhuman cancer patients will activate APC in the tumor draining lymphnodes, enhancing one step of the cancer immunity cycle. However, what isnot well understood by those skilled in the art is that this route ofadministration of high IFN-inducing CpG ODN will also induce TIL andconvert the tumor microenvironment to a more Th1-like state that is moreconducive to induction of clinically beneficial anti-tumor immunity. Theintratumoral administration of high IFN-inducing CpG ODN induces T cellinfiltration into the tumors, notably including CD8⁺ T cellinfiltration. The importance of this is that this CD8⁺ T cellinfiltration into tumors is believed to be the best predictor ofresponse to treatment with anti-PD-1 or anti-PD-L1. Because the humanclinical trials performed in the past with intratumoral administrationof CpG oligonucleotides used B-class ODN, there would have beensignificant local production of IL-10 in the tumor that would haveinhibited the anti-tumor immune response. The present disclosurefeatures improved preferred CpG ODN as well as designs and screens foridentifying the same, which induce lower amounts of IL-10 production andhigher amounts of type I IFN secretion compared to the B-class ODN usedin the past. Such preferred CpG ODN will provide improved synergy incancer therapy when combined with checkpoint inhibitors using themethods of the disclosure.

In various embodiments of the present disclosure, virus-like particles(VLP) are used to formulate one or more CpG ODN.

In one embodiment of the present disclosure, a method of treating cancerin a subject is provided, said method comprising administering at leastone dose of a composition comprising a TLR9 agonist, wherein saidcomposition comprising the TLR9 agonist is administered in a volume ofgreater than 4 mL. As will be appreciated and as described herein, thecomposition comprising the TLR9 agonist may include, 1, 2, 3, 4, 5, 6,7, 8, 9, 10, etc. TLR9 agonists, and that “at least one dose” includes1, 2, 3, 4, 5, 6, 7, 8, 9, 10 etc. doses over a period of time. In oneembodiment, the composition comprising the TLR9 agonist is administeredin a volume of between 5 and 20 mL. In another embodiment, thecomposition comprising the TLR9 agonist is administered in a volume ofbetween 5 and 10 mL. In another embodiment, the composition comprisingthe TLR9 agonist is administered in a volume of 5 mL. In still anotherembodiment, the composition comprising the TLR9 agonist is administeredin a volume of 7 mL.

In another embodiment of the disclosure, the TLR9 agonist induces IFN-γ,α, or β. In a related embodiment, the TLR9 agonist induces IFN-α.

In yet another embodiment, the TLR9 agonist is CpG DNA. In a relatedembodiment, the CpG DNA is selected from the group consisting of A-classCpG DNA, C-class CpG DNA, E-class CpG DNA, A/E-class CpG DNA, P-classCpG DNA, and any combination thereof. In one embodiment, the TLR9agonist is an A-class CpG DNA. In a related embodiment, the sequence ofthe A-class CpG DNA is GGGGGGGGGGGACGATCGTCGGGGGGGGGG (SEQ ID NO:82). Instill another embodiment, the TLR9 agonist is a C-class CpG DNA.

In yet another embodiment of the disclosure, the composition comprisingthe TLR9 agonist is formulated as a virus-like particle (VLP). In arelated embodiment, the aforementioned TLR9 agonist is an A-class CpGDNA. In still another embodiment, the A-class CpG DNA formulated as avirus-like particle (VLP) is CMP-001.

In various embodiments, the composition comprising the TLR9 agonist isadministered via intratumoral, peritumoral, systemic, intravenous,intraperitoneal, enteric, oral, intramuscular, subcutaneous,transmucosal, topical and/or transdermal routes. In one embodiment, thecomposition comprising the TLR9 agonist is administered intratumorally.

In one embodiment, the cancer is associated with a cancerous tumor. Invarious embodiments, the cancerous tumor is a lymphoma or a canceroustumor of a tissue or organ selected from the group consisting of skin,head and neck, esophagus, stomach, liver, colon, rectum, pancreas, lung,breast, cervix, ovary, kidney, bladder, prostate, thyroid, brain,muscle, and bone. In one embodiment, the cancerous tumor is a melanoma.In another embodiment, the cancerous tumor is a lymphoma. In stillanother embodiment, the cancerous tumor is resistant to a treatmentregimen comprising administration of a checkpoint inhibitor (CPI).

In various embodiments, the subject is a human.

In yet another embodiment of the present disclosure, a method oftreating cancer in a subject is provided, said method comprising (a)administering to the subject at least dose of a composition comprising aTLR9 agonist and (b) administering to the subject at least one dose of acomposition comprising a CPI, wherein the composition comprising theTLR9 agonist is administered in a volume of greater than 4 mL. As willbe appreciated and as described herein, the composition comprising theTLR9 agonist and/or the composition comprising a CPI may include, 1, 2,3, 4, 5, 6, 7, 8, 9, 10, etc. TLR9 agonists and/or CPI, and that “atleast one dose” includes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 etc. doses over aperiod of time. In one embodiment, the composition comprising the TLR9agonist is administered in a volume of between 5 and 20 mL. In anotherembodiment, the composition comprising the TLR9 agonist is administeredin a volume of between 5 and 10 mL. In still another embodiment, thecomposition comprising the TLR9 agonist is administered in a volume of 5mL. In yet another embodiment, the composition comprising the TLR9agonist is administered in a volume of 7 mL.

In another embodiment of the disclosure, the TLR9 agonist induces IFN-γ,α, or β. In a related embodiment, the TLR9 agonist induces IFN-α.

In yet another embodiment, the TLR9 agonist is CpG DNA. In a relatedembodiment, the CpG DNA is selected from the group consisting of A-classCpG DNA, C-class CpG DNA, E-class CpG DNA, A/E-class CpG DNA, P-classCpG DNA, and any combination thereof. In one embodiment, the TLR9agonist is an A-class CpG DNA. In a related embodiment, the sequence ofthe A-class CpG DNA is GGGGGGGGGGGACGATCGTCGGGGGGGGGG (SEQ ID NO:82). Instill another embodiment, the TLR9 agonist is a C-class CpG DNA.

In yet another embodiment of the disclosure, the composition comprisingthe TLR9 agonist is formulated as a virus-like particle (VLP). In arelated embodiment, the aforementioned TLR9 agonist is an A-class CpGDNA. In still another embodiment, the A-class CpG DNA formulated as avirus-like particle (VLP) is CMP-001.

In various embodiments, the composition comprising the TLR9 agonist isadministered via intratumoral, peritumoral, systemic, intravenous,intraperitoneal, enteric, oral, intramuscular, subcutaneous,transmucosal, topical and/or transdermal routes. In one embodiment, thecomposition comprising the TLR9 agonist is administered intratumorally.

In one embodiment, the cancer is associated with a cancerous tumor. Invarious embodiments, the cancerous tumor is a lymphoma or a canceroustumor of a tissue or organ selected from the group consisting of skin,head and neck, esophagus, stomach, liver, colon, rectum, pancreas, lung,breast, cervix, ovary, kidney, bladder, prostate, thyroid, brain,muscle, and bone. In one embodiment, the cancerous tumor is a melanoma.In another embodiment, the cancerous tumor is a lymphoma. In stillanother embodiment, the cancerous tumor is resistant to a treatmentregimen comprising administration of a checkpoint inhibitor (CPI).

In various embodiments, the subject is a human.

In still other embodiments of the present disclosure, the compositioncomprising the CPI is administered via intratumoral, peritumoral,systemic, intravenous, intraperitoneal, enteric, oral, intramuscular,subcutaneous, transmucosal, topical and/or transdermal routes.

In other embodiments, the CPI is an antibody or antigen-binding fragmentthereof which binds specifically to an antigen selected from the groupconsisting of PD-1, PD-L1, and CTLA-4. In one embodiment, the CPI is anantibody or antigen-binding fragment thereof which binds specifically toPD-1. In another embodiment, the CPI is an antibody or antigen-bindingfragment thereof which binds specifically to PD-L1. In yet anotherembodiment, the CPI is an antibody or antigen-binding fragment thereofwhich binds specifically to CTLA-4. In some embodiments, the compositioncomprising the CPI comprises a combination of CPIs selected from thegroup consisting of: (a) a first antibody or antigen-binding fragmentthereof which binds specifically to CTLA-4, and a second antibody orantigen-binding fragment thereof which binds specifically to PD-1; (b) afirst antibody or antigen-binding fragment thereof which bindsspecifically to CTLA-4, and a second antibody or antigen-bindingfragment thereof which binds specifically to PD-L1; (c) a first antibodyor antigen-binding fragment thereof which binds specifically to PD-1,and a second antibody or antigen-binding fragment thereof which bindsspecifically to PD-L1.

In related embodiments, the composition comprising the TLR9 agonist isadministered prior to administration of the composition comprising theCPI. In another embodiment, the composition comprising the TLR9 agonistand the composition comprising the CPI are administered substantially atthe same time. In another embodiment, the composition comprising theTLR9 agonist and the composition comprising the CPI are administered viadifferent routes. In another embodiment, the composition comprising theTLR9 agonist and the composition comprising the CPI are administered viathe same route.

In still another embodiment, at least two doses of the compositioncomprising the TLR9 agonist are administered or wherein at least twodoses of the composition comprising the CPI are administered. In anotherembodiment, (a) two doses; (b) three doses; (c) four doses; or (d) fivedoses of the composition comprising the TLR9 agonist are administered.

In another embodiment, the two doses of the composition comprising theTLR9 agonist are administered prior to administration of the compositioncomprising the CPI.

In another embodiment, the composition comprising the CPI isadministered prior to administration of the composition comprising theTLR9 agonist. In another embodiment, the composition comprising the TLR9agonist and the composition comprising the CPI are administeredconcurrently and at least two doses of each composition areadministered. In still another embodiment, the composition comprisingthe TLR9 agonist and the composition comprising the CPI are administeredsequentially and at least two doses of each composition areadministered. In yet another embodiment, the composition comprising theTLR9 agonist and the composition comprising the CPI are administeredsequentially and by the same route. In another embodiment, thecomposition comprising the TLR9 agonist and the composition comprisingthe CPI are administered sequentially and by different routes. Inanother embodiment, the composition comprising the TLR9 agonist isadministered 1 to 3 weeks before the composition comprising the CPI.

In another embodiment, the aforementioned methods are provided furthercomprising administering one or more additional therapeutic agents ortreatments. In a related embodiment, the one or more additionaltherapeutic agents or treatments is selected from the group consistingof an immune checkpoint inhibitor, an antibody that activates aco-stimulatory pathway, a cancer chemotherapy, and radiation therapy.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows the effect of treatment volume on serum IP-10 response toCMP-001 in a single tumor model.

FIG. 2 shows the effect of treatment volume on tumor growth, survival ina single tumor model.

FIG. 3 shows the effect of treatment volume on serum IP-10 response toCMP-001 in a bilateral tumor model.

FIG. 4 shows the effect of treatment volume on tumor growth, survival ina bilateral tumor model.

FIG. 5 shows a varied priming dose study in a mouse B16-OVA model.

FIG. 6 shows a mouse study of dose and concentration effects of SCpriming and IT Tx doses in a B16-OVA model with bilateral tumors.

FIG. 7 shows a mouse study of dosing volume impact on biodistribution ofCMP-001 using IVIS imaging of CT-26 tumor-bearing BALB/c mice.

DETAILED DESCRIPTION OF THE INVENTION

Toll-like receptor (TLR) ligands in general are known to be potentialinducers of the presentation of cancer cell antigens by APC. However, itis not previously known what particular TLR ligands are preferred, andeven in the case of TLR9 ligands, it is not previously known which, ifany, class of CpG ODN is preferred, nor are their preferred doses androutes of administration previously known. Nearly all human clinicaltrials of CpG ODN in oncology have used B-class ODN administered via asystemic route, while a few trials have explored intratumoraladministration (discussed further below).

The invention of immune stimulatory CpG oligodeoxynucleotides (ODN) andsubsequent inventions of various classes and designs of CpG ODN providednew opportunities for cancer immunotherapy. Based on encouragingpreclinical data in rodent models, human clinical trials of CpG ODN havebeen performed in oncology patients using systemic and intratumoraladministration of several different CpG ODN alone or in combination withvarious chemotherapy regimens, vaccines, antibodies, and radiotherapy,but again, clinical responses have been uncommon, and despite someencouraging early clinical trial results, phase 3 trials have so farfailed (reviewed in Krieg, Nucleic Acid Ther. 2012 22(2): 77-89).Therefore, there exists a need to provide improved oligonucleotidetherapeutic approaches to increase the success rate of cancerimmunotherapy.

Tumor vaccines in which a cancer patient is vaccinated with a conservedunmutated self antigen together with an adjuvant have been a goal ofimmuno-oncologists for many years, yet despite successfully inducingimmunity against the selected antigen, have almost uniformly failed todeliver clear clinical benefits. B-class CpG ODN have enhanced theinduction of anti-tumor CD8⁺ T cell responses in multiple cancer vaccineclinical trials (for example, Kruit et al., J Clin Oncol 2013; Tarhiniet al., J Immunother 2013; Lovgren et al., Cancer Immunol Immunother2012; Karbach et al., Clin Cancer Res 2011; Karbach et al., Int J Cancer2010; Speiser et al., JCI 2005, and in a single trial an unmodifiedA-class CpG ODN was used as a vaccine adjuvant (Speiser et al., J.Immunother 2010), yet these have seldom been associated with clinicalresponses, and a phase 3 clinical trial of this approach conducted byGSK (GlaxoSmithKline) using the MAGE-3 tumor antigen so far appears tohave been a failure. In particular it is noteworthy that the vaccineclinical trial using an A-class CpG ODN showed relatively weak inductionof a CTL response that increased approximately two-fold from baseline inonly about half of the patients, compared to an approximate average10-fold increased CTL response in those melanoma patients previouslyvaccinated using B-class CpG ODN, indicating the state of the art. It ispossible that the immune system will not easily overcome self-toleranceto unmutated self-antigens to a degree sufficient to reject a tumor,leading many of those skilled in the art to search for ways to inducetumor immunity against alternative, mutated tumor antigens. Recentstudies using deep sequencing of tumor transcriptomes have revealed thatall cancers contain variable numbers of unique mutated antigens,referred to as tumor-specific neoantigens (Rajasagi et al., Blood 2014124(3): 453-462), and those skilled in the art have sought ways todirect the anti-tumor immune response against such antigens. Oneapproach being pursued is to synthesize some or all of these neoantigensas peptides, and to vaccinate a cancer patient with the appropriateantigenic peptides to be presented on Class II MHC in a formulation suchas viral-like particle and using a very strong adjuvant, such as a CpGB-class ODN. Such an approach would be extremely complex and expensiveto develop. Therefore, there is a need for improved methods to induceanti-tumor immune responses against tumor-specific neoantigens.

The present disclosure provides a superior approach by turning the tumoritself into a vaccine, due to altering the tumor microenvironment insuch a way as to disengage the “brakes” with checkpoint inhibitors,while inducing strong cell-mediated immunity, using TLR9 agonists.

Radiotherapy has long been used in the treatment of cancer, and it iscurrently employed in the treatment of approximately 60% of patientswith solid tumors (reviewed in Prasanna et al., J Thoracic Dis. 20146(4):287-302). Although radiotherapy often can shrink tumors, thiseffect is most commonly palliative, and durable responses are extremelyuncommon. Moreover, radiotherapy is generally only suitable for treatingone or a small number of tumor lesions, and thus is not generally usedin the treatment of metastatic cancer.

In some unusual cases, XRT can lead to regression of distant tumormasses as a result of the induction of a specific immune responseagainst tumor antigens present not only in the irradiated lesion, butalso in distant metastases. This has been termed an “abscopal effect”,and particularly since a recent case report by Postow et al. (N. Engl.J. Med. 2012 366(10): 925-31), this term has come to be used to includeother forms of localized tumor therapy besides just radiotherapy.

Abscopal effects can be seen when XRT is given either before or afteranti-CTLA-4 therapy: for example, more than half of 21 melanoma patientstreated with XRT following anti-CTLA-4 therapy showed evidence fordistal tumor regressions (Grimaldi et al., Oncoimmunol. 2014 3: e28780).

I. Definitions

Unless otherwise defined herein, scientific and technical terms used inconnection with the present disclosure shall have the meanings that arecommonly understood by those of ordinary skill in the art. Further,unless otherwise required by context, singular terms shall includepluralities and plural terms shall include the singular. Generally,nomenclatures used in connection with, and techniques of, cell andtissue culture, molecular biology, immunology, microbiology, geneticsand protein and nucleic acid chemistry and hybridization describedherein are those well-known and commonly used in the art.

The methods and techniques of the present disclosure are generallyperformed according to methods well known in the art and as described invarious general and more specific references that are cited anddiscussed throughout the present specification unless otherwiseindicated. Such references include, e.g., Sambrook and Russell,Molecular Cloning, A Laboratory Approach, Cold Spring Harbor Press, ColdSpring Harbor, N.Y. (2001), Ausubel et al., Current Protocols inMolecular Biology, John Wiley & Sons, NY (2002), and Harlow and LaneAntibodies: A Laboratory Manual, Cold Spring Harbor Laboratory Press,Cold Spring Harbor, N.Y. (1990), which are incorporated herein byreference. Enzymatic reactions and purification techniques are performedaccording to manufacturer's specifications, as commonly accomplished inthe art or as described herein. The nomenclatures used in connectionwith, and the laboratory procedures and techniques of, analyticalchemistry, synthetic organic chemistry, and medicinal and pharmaceuticalchemistry described herein are those well-known and commonly used in theart. Standard techniques are used for chemical syntheses, chemicalanalyses, pharmaceutical preparation, formulation, and delivery, andtreatment of patients.

As used herein, each of the following terms has the meaning associatedwith it in this section.

The articles “a” and “an” are used herein to refer to one or to morethan one (i.e., to at least one) of the grammatical object of thearticle. By way of example, “an element” means one element or more thanone element.

As used herein, the twenty conventional amino acids and theirabbreviations follow conventional usage. See Immunology—A Synthesis (2ndEdition, E. S. Golub and D. R. Gren, Eds., Sinauer Associates,Sunderland, Mass. (1991)), which is incorporated herein by reference.

Conventional notation is used herein to portray polypeptide sequences:the left-hand end of a polypeptide sequence is the amino-terminus; theright-hand end of a polypeptide sequence is the carboxyl-terminus.

A “conservative amino acid substitution” is one in which an amino acidresidue is substituted by another amino acid residue having a side chainR group with similar chemical properties (e.g., charge orhydrophobicity). In general, a conservative amino acid substitution willnot substantially change the functional properties of a protein. Incases where two or more amino acid sequences differ from each other byconservative substitutions, the percent sequence identity or degree ofsimilarity may be adjusted upwards to correct for the conservativenature of the substitution. Means for making this adjustment arewell-known to those of skill in the art. See, e.g., Pearson, MethodsMol. Biol. 243:307-31 (1994).

Examples of groups of amino acids that have side chains with similarchemical properties include 1) aliphatic side chains: glycine, alanine,valine, leucine, and isoleucine; 2) aliphatic-hydroxyl side chains:serine and threonine; 3) amide-containing side chains: asparagine andglutamine; 4) aromatic side chains: phenylalanine, tyrosine, andtryptophan; 5) basic side chains: lysine, arginine, and histidine; 6)acidic side chains: aspartic acid and glutamic acid; and 7)sulfur-containing side chains: cysteine and methionine. Preferredconservative amino acids substitution groups are:valine-leucine-isoleucine, phenylalanine-tyrosine, lysine-arginine,alanine-valine, glutamate-aspartate, and asparagine-glutamine.

Alternatively, a conservative replacement is any change having apositive value in the PAM250 log-likelihood matrix disclosed in Gonnetet al., Science 256:1443-45 (1992), incorporated herein by reference. A“moderately conservative” replacement is any change having a nonnegativevalue in the PAM250 log-likelihood matrix.

Preferred amino acid substitutions are those which: (1) reducesusceptibility to proteolysis, (2) reduce susceptibility to oxidation,(3) alter binding affinity for forming protein complexes, and (4) conferor modify other physicochemical or functional properties of suchanalogs. Analogs comprising substitutions, deletions, and/or insertionscan include various muteins of a sequence other than thenaturally-occurring peptide sequence. For example, single or multipleamino acid substitutions (preferably conservative amino acidsubstitutions) may be made in the naturally-occurring sequence(preferably in the portion of the polypeptide outside the domain(s)forming intermolecular contacts). A conservative amino acid substitutionshould not substantially change the structural characteristics of theparent sequence (e.g., a replacement amino acid should not tend to breaka helix that occurs in the parent sequence, or disrupt other types ofsecondary structure that characterizes the parent sequence). Examples ofart-recognized polypeptide secondary and tertiary structures aredescribed in Proteins, Structures and Molecular Principles (Creighton,Ed., W. H. Freeman and Company, New York (1984)); Introduction toProtein Structure (C. Branden and J. Tooze, eds., Garland Publishing,New York, N.Y. (1991)); and Thornton et al., Nature 354:105 (1991),which are each incorporated herein by reference.

Sequence similarity for polypeptides, and similarly sequence identityfor polypeptides, is typically measured using sequence analysissoftware. Protein analysis software matches similar sequences usingmeasures of similarity assigned to various substitutions, deletions andother modifications, including conservative amino acid substitutions.For instance, GCG contains programs such as “Gap” and “Bestfit” whichcan be used with default parameters to determine sequence homology orsequence identity between closely related polypeptides, such ashomologous polypeptides from different species of organisms or between awild type protein and a mutein thereof. See, e.g., GCG Version 6.1.Polypeptide sequences also can be compared using FASTA using default orrecommended parameters, a program in GCG Version 6.1. FASTA (e.g.,FASTA2 and FASTA3) provides alignments and percent sequence identity ofthe regions of the best overlap between the query and search sequences(Pearson, Methods Enzymol. 183:63-98 (1990); Pearson, Methods Mol. Biol.132:185-219 (2000)). Another preferred algorithm when comparing asequence of the invention to a database containing a large number ofsequences from different organisms is the computer program BLAST,especially blastp or tblastn, using default parameters. See, e.g.,Altschul et al., J. Mol. Biol. 215:403-410 (1990); Altschul et al.,Nucleic Acids Res. 25:3389-402 (1997); incorporated herein by reference.

An intact “antibody” comprises at least two heavy (H) chains and twolight (L) chains inter-connected by disulfide bonds. See generally,Fundamental Immunology, Ch. 7 (Paul, W., ed., 2nd ed. Raven Press, N.Y.(1989)) (incorporated herein by reference in its entirety for allpurposes). Each heavy chain is comprised of a heavy chain variableregion (HCVR or V_(H)) and a heavy chain constant region (C_(H)). Theheavy chain constant region is comprised of three domains, CH1, CH2 andCH3. Each light chain is comprised of a light chain variable region(LCVR or V_(L)) and a light chain constant region. The light chainconstant region is comprised of one domain, C_(L). The V_(H) and V_(L)regions can be further subdivided into regions of hypervariability,termed complementarity determining regions (CDR), interspersed withregions that are more conserved, termed framework regions (FR). EachV_(H) and V_(L) is composed of three CDRs and four FRs, arranged fromamino-terminus to carboxyl-terminus in the following order: FR1, CDR1,FR2, CDR2, FR3, CDR3, FR4. The assignment of amino acids to each domainis in accordance with the definitions of Kabat, Sequences of Proteins ofImmunological Interest (National Institutes of Health, Bethesda, Md.(1987 and 1991)), or Chothia & Lesk, J. Mol. Biol. 196:901-917 (1987);Chothia et al., Nature 342:878-883 (1989).

The variable regions of the heavy and light chains contain a bindingdomain that interacts with an antigen. The constant regions of theantibodies may mediate the binding of the immunoglobulin to host tissuesor factors, including various cells of the immune system (e.g., effectorcells) and the first component (C1q) of the classical complement system.

The term “antibody” can include antigen-binding portions of an intactantibody that retain capacity to specifically bind the antigen of theintact antibody, e.g., PD-1. Antigen-binding portions may be produced byrecombinant DNA techniques or by enzymatic or chemical cleavage ofintact antibodies.

Examples of antigen-binding portions include (i) a Fab fragment, amonovalent fragment consisting of the V_(L), V_(H), C_(L) and CH1domains; (ii) a F(ab′)₂ fragment, a bivalent fragment comprising two Fabfragments linked by a disulfide bridge at the hinge region; (iii) a Fdfragment consisting of the V_(H) and CH1 domains; (iv) a Fv fragmentconsisting of the V_(L) and V_(H) domains of a single arm of anantibody, (v) a single domain antibody (“dAb”), which consists of aV_(H) domain as described in Ward et al., Nature 341:544-546 (1989); and(vi) an isolated complementarity determining region (CDR). Furthermore,although the two domains of the Fv fragment, V_(H) and V_(L), are codedfor by separate genes, they can be joined, using recombinant methods, bya synthetic linker that enables them to be made as a single proteinchain in which the V_(H) and V_(L) regions pair to form monovalentmolecules (known as single chain Fv (scFv); See, e.g., Bird et al.Science 242:423-426 (1988); and Huston et al. Proc. Natl. Acad. Sci. USA85:5879-5883 (1988)). Such single chain antibodies are included byreference to the term “antibody”.

A “bispecific antibody” has two different binding specificities, see,e.g., U.S. Pat. Nos. 5,922,845 and 5,837,243; Zeilder J. Immunol.163:1246-1252 (1999); Somasundaram Hum. Antibodies 9:47-54 (1999); KelerCancer Res. 57:4008-4014 (1997). For example, the invention providesbispecific antibodies having one binding site for a cell surfaceantigen, such as human PD-1, and a second binding site for an Fcreceptor on the surface of an effector cell. The invention also providesmultispecific antibodies, which have at least three binding sites.

Contemplated by the present disclosure are bispecific antibodies whichbind any two different checkpoint molecules. For example, the differentcheckpoints may be selected from the group consisting of PD-1, PD-L1,CTLA-4, TIM3, and LAG3. Thus, for example, bispecfic antibodies may bindPD-1 and PD-L1, PD-1 and CTLA-4, PD-1 and TIM3, PD-1 and LAG3, PD-L1 andCTLA-4, PD-L1 and TIM3, PD-L1 and LAG3, CTLA-4 and TIM3, and CTLA-4 andLAG3, or TIM3 and LAG3. In certain embodiments, the bispecfic antibodiesmay bind PD-1 and PD-L1, PD-1 and CTLA-4, PD-1 and TIM3, or PD-1 andLAG3. In certain embodiments, the bispecific antibodies may bind PD-L1and CTLA-4, PD-L1 and TIM3, PD-L1 and LAG3. In certain embodiments, thebispecfic antibodies may bind PD-1 and PD-L1, or PD-1 and CTLA-4. Incertain embodiments, the bispecfic antibodies may bind PD-1 and PD-L1.In certain embodiments, the bispecfic antibodies may bind PD-L1 andCTLA-4. In certain embodiments, the bispecfic antibodies may bind PD-L1and CTLA-4.

Also contemplated by the present disclosure are methods of the inventionusing bispecific antibodies which bind any two different checkpointmolecules. For example, the different checkpoints may be selected fromthe group consisting of PD-1, PD-L1, CTLA-4, TIM3, and LAG3. Thus, forexample, bispecfic antibodies may bind PD-1 and PD-L1, PD-1 and CTLA-4,PD-1 and TIM3, PD-1 and LAG3, PD-L1 and CTLA-4, PD-L1 and TIM3, PD-L1and LAG3, CTLA-4 and TIM3, and CTLA-4 and LAG3, or TIM3 and LAG3. Incertain embodiments, the bispecfic antibodies may bind PD-1 and PD-L1,PD-1 and CTLA-4, PD-1 and TIM3, or PD-1 and LAG3. In certainembodiments, the bispecific antibodies may bind PD-L1 and CTLA-4, PD-L1and TIM3, PD-L1 and LAG3. In certain embodiments, the bispecficantibodies may bind PD-1 and PD-L1, or PD-1 and CTLA-4. In certainembodiments, the bispecfic antibodies may bind PD-1 and PD-L1. Incertain embodiments, the bispecfic antibodies may bind PD-L1 and CTLA-4.In certain embodiments, the bispecfic antibodies may bind PD-L1 andCTLA-4.

The term “bispecific antibodies” further includes “diabodies.” Diabodiesare bivalent, bispecific antibodies in which the V_(H) and V_(L) domainsare expressed on a single polypeptide chain, but using a linker that istoo short to allow for pairing between the two domains on the samechain, thereby forcing the domains to pair with complementary domains ofanother chain and creating two antigen binding sites (See, e.g.,Holliger et al., Proc. Natl. Acad. Sci. USA 90:6444-6448 (1993); Pollaket al., Structure 2:1121-1123 (1994)).

The terms “human antibody” or “human sequence antibody”, as usedinterchangeably herein, include antibodies having variable and constantregions (if present) derived from human germline immunoglobulinsequences. The human sequence antibodies of the invention may includeamino acid residues not encoded by human germline immunoglobulinsequences (e.g., mutations introduced by random or site-specificmutagenesis in vitro or by somatic mutation in vivo). However, the term“human antibody”, as used herein, is not intended to include “chimeric”antibodies in which CDR sequences derived from the germline of anothermammalian species, such as a mouse, have been grafted onto humanframework sequences (i.e., “humanized” or PRIMATIZED™ antibodies).

The term “chimeric antibody” as used herein means an antibody thatcomprises regions from two or more different antibodies. For example, inone embodiment, one or more of the CDRs are derived from a humananti-CTLA-4 antibody. In another embodiment, all of the CDRs are derivedfrom a human anti-CTLA-4 antibody. In another embodiment, the CDRs frommore than one human anti-CTLA-4 antibody are combined in a chimerichuman antibody. For instance, a chimeric antibody may comprise a CDR1from the light chain of a first human anti-CTLA-4 antibody, a CDR2 fromthe light chain of a second human anti-CTLA-4 antibody, and a CDR3 fromthe light chain of a third human anti-CTLA-4 antibody; and similarly theCDRs from the heavy chain may be derived from one or more otheranti-CTLA-4 antibodies. Further, the framework regions may be derivedfrom one of the same anti-CTLA-4 antibodies or from one or moredifferent human(s).

As another example, in one embodiment, one or more of the CDRs arederived from a human anti-PD-1 antibody. In another embodiment, all ofthe CDRs are derived from a human anti-PD-1 antibody. In anotherembodiment, the CDRs from more than one human anti-PD-1 antibody arecombined in a chimeric human antibody. For instance, a chimeric antibodymay comprise a CDR1 from the light chain of a first human anti-PD-1antibody, a CDR2 from the light chain of a second human anti-PD-1antibody, and a CDR3 from the light chain of a third human anti-PD-1antibody; and similarly the CDRs from the heavy chain may be derivedfrom one or more other anti-PD-1 antibodies. Further, the frameworkregions may be derived from one of the same anti-PD-1 antibodies or fromone or more different human(s).

As yet another example, in one embodiment, one or more of the CDRs arederived from a human anti-PD-L1 antibody. In another embodiment, all ofthe CDRs are derived from a human anti-PD-L1 antibody. In anotherembodiment, the CDRs from more than one human anti-PD-L1 antibody arecombined in a chimeric human antibody. For instance, a chimeric antibodymay comprise a CDR1 from the light chain of a first human anti-PD-L1antibody, a CDR2 from the light chain of a second human anti-PD-L1antibody, and a CDR3 from the light chain of a third human anti-PD-L1antibody; and similarly the CDRs from the heavy chain may be derivedfrom one or more other anti-PD-L1 antibodies. Further, the frameworkregions may be derived from one of the same anti-PD-L1 antibodies orfrom one or more different human(s).

Moreover, as discussed previously herein, chimeric antibody includes anantibody comprising a portion derived from the germline sequences ofmore than one species.

By the term “compete”, as used herein with regard to an antibody, ismeant that a first antibody, or an antigen-binding portion thereof,competes for binding with a second antibody, or an antigen-bindingportion thereof, where binding of the first antibody with its cognateepitope is detectably decreased in the presence of the second antibodycompared to the binding of the first antibody in the absence of thesecond antibody. The alternative, where the binding of the secondantibody to its epitope is also detectably decreased in the presence ofthe first antibody, can, but need not be the case. That is, a firstantibody can inhibit the binding of a second antibody to its epitopewithout that second antibody inhibiting the binding of the firstantibody to its respective epitope. However, where each antibodydetectably inhibits the binding of the other antibody with its cognateepitope or ligand, whether to the same, greater, or lesser extent, theantibodies are said to “cross-compete” with each other for binding oftheir respective epitope(s). For instance, cross-competing antibodiescan bind to the epitope, or portion of the epitope, to which antibodiesof the invention bind. Both competing and cross-competing antibodies areencompassed by the present disclosure. Regardless of the mechanism bywhich such competition or cross-competition occurs (e.g., sterichindrance, conformational change, or binding to a common epitope, orportion thereof, and the like), the skilled artisan would appreciate,based upon the teachings provided herein, that such competing and/orcross-competing antibodies are encompassed and can be useful for themethods disclosed herein.

The term “epitope” includes any protein determinant capable of specificbinding to an immunoglobulin or T-cell receptor. Epitopic determinantsusually consist of chemically active surface groupings of molecules suchas amino acids or sugar side chains and usually have specificthree-dimensional structural characteristics, as well as specific chargecharacteristics. Conformational and non-conformational epitopes aredistinguished in that the binding to the former but not the latter islost in the presence of denaturing solvents.

By the phrase “specifically binds,” as used herein, is meant a compound,e.g., a protein, a nucleic acid, an antibody, and the like, whichrecognizes and binds a specific molecule, but does not substantiallyrecognize or bind other molecules in a sample. For instance, the phrase“specifically binds” may characterize an antibody or a peptide inhibitorwhich recognizes and binds a cognate ligand (e.g., an anti-PD-1 antibodythat binds with its cognate antigen, PD-1) in a sample, but does notsubstantially recognize or bind other molecules in the sample. Thus,under designated assay conditions, the specified binding moiety (e.g.,an antibody or an antigen-binding portion thereof) binds preferentiallyto a particular target molecule and does not bind in a significantamount to other components present in a test sample. A variety of assayformats may be used to select an antibody that specifically binds amolecule of interest. For example, solid-phase ELISA immunoassay,immunoprecipitation, BIAcore and Western blot analysis are used toidentify an antibody that specifically reacts with PD-1. Typically aspecific or selective reaction will be at least twice background signalor noise and more typically more than 10 times background, even morespecifically, an antibody is said to “specifically bind” an antigen whenthe equilibrium dissociation constant (K_(D)) is ≤1 μM, preferably ≤100nM, and most preferably ≤10 nM.

Preferably, an “antibody which binds specifically to a checkpointmolecule” is an antibody or antigen-binding fragment thereof, which, inaddition to binding its target CPI, interferes with reciprocalinteraction between the bound target CPI and its cognate ligand. Forexample, an antibody which binds specifically to PD-1 preferably is anantibody or antigen-binding fragment thereof, which, in addition tobinding PD-1, interferes with reciprocal interaction between PD-1 andits cognate ligand, PD-L1.

The term “K_(D)” refers to the equilibrium dissociation constant of aparticular antibody-antigen interaction.

As used herein, “substantially pure” means an object species is thepredominant species present (i.e., on a molar basis it is more abundantthan any other individual species in the composition), and preferably asubstantially purified fraction is a composition wherein the objectspecies (e.g., an anti-PD-1 antibody) comprises at least about 50percent (on a molar basis) of all macromolecular species present.Generally, a substantially pure composition will comprise more thanabout 80 percent of all macromolecular species present in thecomposition, more preferably more than about 85%, 90%, 95%, and 99%.Most preferably, the object species is purified to essential homogeneity(contaminant species cannot be detected in the composition byconventional detection methods) wherein the composition consistsessentially of a single macromolecular species.

By the term “therapeutically effective amount,” as used herein, is meantan amount that when administered to a mammal, preferably a human,mediates a detectable therapeutic response compared to the responsedetected in the absence of the compound. A therapeutic response, suchas, but not limited to, inhibition of and/or decreased tumor growth(including tumor size stasis), tumor size, metastasis, and the like, canbe readily assessed by a plethora of art-recognized methods, including,e.g., such methods as disclosed herein.

The skilled artisan would understand that the effective amount of thecompound or composition administered herein varies and can be readilydetermined based on a number of factors such as the disease or conditionbeing treated, the stage of the disease, the age and health and physicalcondition of the mammal being treated, the severity of the disease, theparticular compound being administered, and the like.

A “therapeutically effective amount” is intended to qualify the amountof an agent required to detectably reduce to some extent one or more ofthe symptoms of a neoplastic disorder, including, but not limited to: 1)reduction in the number of cancer cells; 2) reduction in tumor size; 3)inhibition (i.e., slowing to some extent, preferably stopping) of cancercell infiltration into peripheral organs; 4) inhibition (i.e., slowingto some extent, preferably stopping) of tumor metastasis; 5) inhibition,to some extent, of tumor growth; 6) relieving or reducing to some extentone or more of the symptoms associated with the disorder; and/or 7)relieving or reducing the side effects associated with theadministration of anticancer agents.

A “therapeutically effective amount” of a TLR9 agonist can also bedefined based on a biomarker response using any of the well-definedblood or tissue markers for TLR9 activation that are well known to thoseskilled in the art. The CpG ODN of the present disclosure are broadlysimilar to other CpG ODN (e.g., B-class) in their induction of aTh1-like cytokine and chemokine response in the serum, plasma, PBMC,and/or tissues or biopsies, which can be measured as described by Krieget al., J. Immunother., 2004 27:460-471 using for example cytokineassays for IP-10, I-TAC, MIG, MIP-1β, MIP-33, IL-6, IL-12p40, or IFN-αfrom serum or plasma collected approximately 24 hr after the treatment,or can also be assessed by RT-PCR assays of PBMC. A therapeuticallyeffective amount of the CpG ODN that is injected intratumorally into acancer patient will increase serum IP-10 levels by 24 hours to at least100 pg/ml, and preferably to between 100-100,000 pg/ml, and mostpreferably to between 1,000 to 10,000 pg/mL.

In contrast to chemotherapy drugs, for which the dose is generallyescalated to the maximal tolerated dose (MTD), immune stimulatory drugssuch as the CpG ODN of the present disclosure function best at anoptimal biologic dose (OBD), which is generally below the MTD. The serumcytokines and chemokines provide one simple measure to estimate theoptimal biologic dose. The intended biologic effect of the CpG ODN ofthe present disclosure is to convert the tumor microenvironment (andthat of the draining lymph nodes) from immunosuppressive—with a lowlevel of IFN production and lacking in activated TIL—to an immuneactivated microenvironment that shows increased production of IFN,especially type I IFN, and which now has increased TIL that displayactivation markers such as PD-L1, as reflected for example in the tumorbiopsy characteristics of patients responding to treatment withanti-PD-1 or anti-PD-L1 reported by Tumeh et. al., Nature 2014515:568-571; and by Herbst et al., Nature 2014 515:563-567,respectively, or additionally by Taube et al., Clin Cancer Res. 2014.Expressed another way, recent studies have demonstrated that anti-PD-1or anti-PD-L1 therapy is generally only effective in patients whoalready have TIL, and already have a tumor microenvironment thatreflects IFN effects (such as expression of PD-L1, which is induced byIFN). Patients who lack these characteristics on a pre-treatment tumorbiopsy are unlikely to respond to therapy with anti-PD-1 or anti-PD-L1unless they also receive treatment with an agent that induces TIL andhigh production of type I IFN: the CpG ODN of the present disclosure arethe perfect agent for this purpose.

The major endogenous source of type I IFN in humans and other animals isthe plasmacytoid dendritic cell (pDC). pDC produce more than 99% of thetype I IFN that is made in response to pathogen infection (Siegal etal., Science 1999). Yet very few molecularly-defined stimuli have beenshown to activate the pDC to secrete high levels of type I IFN. In fact,to date A-class CpG ODN are by far the strongest stimulus for pDCproduction of type I IFN that have been reported in the scientificliterature, and, surprisingly, the CpG ODN of the present disclosure areeven more effective than those previously known in the art.

Certain preferred CpG ODN induce high or large amounts of type I IFN.Assays for measuring type I IFN are well known in the art and include invitro enzyme-linked immunosorbent assay (ELISA) and cell-based assays,such as are described herein. Without meaning to be limiting, large orhigh amounts of type I IFN can refer to greater than or equal to about1000 pg/mL IFN-α as measured according to such in vitro assays. Incertain embodiments, large or high amounts of type I IFN can refer togreater than or equal to about 2000 pg/mL IFN-α as measured according tosuch in vitro assays. In certain embodiments, large or high amounts oftype I IFN can refer to greater than or equal to about 3000 pg/mL IFN-αas measured according to such in vitro assays. In certain embodiments,large or high amounts of type I IFN can refer to greater than or equalto about 4000 pg/mL IFN-α as measured according to such in vitro assays.In certain embodiments, large or high amounts of type I IFN can refer togreater than or equal to about 5,000 pg/mL IFN-α as measured accordingto such in vitro assays.

Combined with the teachings provided herein, by choosing among thevarious active compounds and weighing factors such as potency, relativebioavailability, patient body weight, severity of adverse side-effectsand preferred mode of administration, an effective prophylactic ortherapeutic treatment regimen can be planned which does not causesubstantial toxicity and yet is effective to treat the particularsubject. The effective amount for any particular application can varydepending on such factors as the disease or condition being treated, theseverity of the disease or condition, and the health and size of thesubject. One of ordinary skill in the art can empirically determine theeffective amount of TLR9 agonist (e.g., CpG ODN), CPI (e.g., anti-PD-1antibodies, anti-PD-L1 antibodies, anti-CTLA-4 antibodies), and/or othertherapeutic agent(s) without necessitating undue experimentation.

For example, a human clinical trial of a B-class CpG ODN together withan anti-CTLA-4 antibody was reported by Millward et al., 2013. Theclinical trial demonstrated a way to combine a TLR9 agonist given bysubcutaneous injection with an anti-CTLA-4 antibody given systemicallythat could be used in future clinical trials of other CpG ODN and othercheckpoint inhibitors, but the trial failed to demonstrate significantclear clinical benefit from the combination. This failure demonstratesthe non-obviousness of the present disclosure. Even though there havebeen publications of A-class CpG ODN with high IFN-α secretion, it wasnot obvious to the investigators running the clinical trial to use sucha CpG ODN instead of the B-class CpG ODN. It was not obvious to give theCpG ODN or anti-CTLA-4 antibody locally into the tumor instead of by thesystemic route. As a result, the approach was abandoned following thecompletion of the trial. Likewise, Mangsbo et al. (J. Immunother 201033:225) reported the combination of an intratumoral B-class CpG ODN withanti-CTLA-4 or anti-PD-1 in mouse tumor models. Positive results wereseen with the combinations, but again, there was no guidance to performsuch therapy using a high IFN-inducing type of CpG ODN, such as theA-class or other ODN of the present disclosure.

To date, there appears to be no realization among those skilled in thefield of the desirability and advantage to combine a high-IFN-inducingclass of CpG ODN together with checkpoint inhibitor therapy. For acombination of agents to have optimal synergy in cancer immunotherapy,the immune suppressive effects of one agent should be reversed byanother. For example, IFN induce the expression of PD-L1 on tumors,which suppresses the immune response. High IFN-inducing CpG ODN of theinvention induce the expression of PD-L1, but when they are used incombination with an anti-PD-L1 antibody or an anti-PD-L1 antibody, thepotential immune suppressive effects of the PD-L1 are overcome by theantibody. On the other hand, the present disclosure is based, at leastin part, on the discovery that the combination of an intratumoralB-class CpG ODN with a systemic checkpoint inhibitor will be less thanoptimally synergistic (or not synergistic at all) because the inductionof IL-10 results in pleiotropic immune suppressive effects that are notreversed by checkpoint inhibitor therapy. Thus, the present disclosureprovides combinations of agents that together provide unexpected, e.g.,synergistic, benefits in cancer immunotherapy.

The therapeutically effective amount of CpG ODN and/or antibodies aloneor together can be initially determined from in vitro and/or animalmodels. A therapeutically effective dose can also be determined fromhuman data for the specific CpG ODN and/or specific antibodies or forother compounds which are known to exhibit similar pharmacologicalactivities. The applied dose can be adjusted based on the relativebioavailability and potency of the administered compound. Adjusting thedose to achieve maximal efficacy based on the methods described aboveand other methods as are well-known in the art is well within thecapabilities of the ordinarily skilled artisan.

“Instructional material”, as that term is used herein, includes apublication, a recording, a diagram, or any other medium of expressionwhich can be used to communicate the usefulness of the compound,combination, and/or composition of the invention in the kit foraffecting, alleviating or treating the various diseases or disordersrecited herein. Optionally, or alternately, the instructional materialcan describe one or more methods of alleviating the diseases ordisorders in a cell, a tissue, or a mammal, including as disclosedelsewhere herein.

The instructional material of the kit may, for example, be affixed to acontainer that contains the compound and/or composition of the inventionor be shipped together with a container which contains the compoundand/or composition. Alternatively, the instructional material may beshipped separately from the container with the intention that therecipient uses the instructional material and the compoundcooperatively.

The CpG ODN and/or antibody of the invention may be provided in amedicinal dispenser. A medical dispenser is a package defining aplurality of medicinal storage compartments, each compartment forhousing an individual unit of medicament. In an embodiment, an entiremedicinal course of treatment is housed in a plurality of medicinalstorage compartments.

A package defining a plurality of medicinal storage compartments may beany type of disposable pharmaceutical package or card which holdsmedicaments in individual compartments. For example, the package is ablister package constructed from a card, which may be made from stiffpaper material, a blister sheet and backing sheet. Such cards are wellknown to those of ordinary skill in the art.

As an example, a medicinal dispenser may house an entire medicinalcourse of treatment. The dispenser may include the day indicia toindicate which day the individual units of medicament are to be taken.These may be marked along a first side of the medicinal package. Thedose indicia may also be marked, for example along a second side of themedicinal package perpendicular to the first side of the medicinalpackage, thereby indicating the time which the individual unit ofmedicament should be taken. The unit doses may be contained in thedispenser which is a blister pack.

Except when noted, the terms “patient” or “subject” are usedinterchangeably and refer to mammals such as human patients andnon-human primates, as well as veterinary subjects such as rabbits,rats, and mice, and other animals. Preferably, “patient” or “subject”refers to a human.

In certain embodiments, a subject is an adult human.

In certain embodiments, a subject is a child. In certain embodiments, asubject is less than about 18 years of age. In certain embodiments, asubject is less than about 12 years of age.

As used herein, to “treat” means reducing the frequency with whichsymptoms of a disease (i.e., tumor growth and/or metastasis, or othereffect mediated by the numbers and/or activity of immune cells, and thelike) are experienced by a patient. Treatment may be prophylactic (toprevent or delay the onset of the disease, or to prevent themanifestation of clinical or subclinical symptoms thereof) ortherapeutic suppression or alleviation of symptoms after themanifestation of the disease. The term “treat” includes theadministration of the compounds or agents of the present disclosure to(i) prevent or delay the onset of the symptoms, complications, orbiochemical indicia of, (ii) alleviate the symptoms of, and/or (iii)inhibit or arrest the further development of, the disease, condition, ordisorder.

“Combination therapy” embraces the administration of a TLR9 agonist,e.g., certain CpG ODN, and a checkpoint inhibitor as part of a specifictreatment regimen intended to provide a beneficial effect from theco-action of these therapeutic agents. In some embodiments, thecheckpoint inhibitor is a CPI-specific antibody or antigen-bindingfragment thereof. In some embodiments, the checkpoint inhibitor is abispecific CPI-specific antibody or bispecific antigen-binding fragmentthereof. The beneficial effect of the combination includes, but is notlimited to, pharmacokinetic or pharmacodynamic co-action resulting fromthe combination of therapeutic agents. Administration of thesetherapeutic agents in combination typically is carried out over adefined time period (usually minutes, hours, days, or weeks dependingupon the combination selected). “Combination therapy” generally is notintended to encompass the administration of two or more of thesetherapeutic agents as part of separate monotherapy regimens thatincidentally and arbitrarily result in the combinations of the presentdisclosure.

“Combination therapy” embraces administration of these therapeuticagents in a sequential manner, that is, wherein each therapeutic agentis administered at a different time, as well as administration of thesetherapeutic agents, or at least two of the therapeutic agents, in asubstantially simultaneous manner. Sequential or substantiallysimultaneous administration of each therapeutic agent can be effected byany appropriate route as described herein, including, but not limitedto, intratumoral and peritumoral routes; systemic routes, e.g.,intravenous, intraperitoneal, enteric (including oral), intramuscular,subcutaneous, and transmucosal routes; and topical and transdermalroutes. As described herein, generally a first therapeutic agent (e.g.,CpG ODN) can be administered by intratumoral or peritumoral injection,and a second agent (e.g., anti-PD-1 antibody) can be administeredsystemically (e.g., intravenously).

“Combination therapy” also can embrace the administration of the TLR9agonist, e.g., certain CpG ODN, and checkpoint inhibitor therapeuticagents as described above in further combination with non-drug therapies(such as, but not limited to, radiotherapy (XRT) or surgery). In someembodiments, the checkpoint inhibitor is a checkpoint-specific antibodyor antigen-binding fragment thereof. In some embodiments, the checkpointinhibitor is a bispecific CPI-specific antibody or bispecificantigen-binding fragment thereof. Where the combination therapy furthercomprises radiation treatment, the radiation treatment may be conductedat any suitable time so long as a beneficial effect from the co-actionof the combination of the therapeutic agents and radiation treatment isachieved. For example, in appropriate cases, the beneficial effect isstill achieved when the radiation treatment is temporally removed fromthe administration of the therapeutic agents, by days or even weeks.

“Combination therapy” also can embrace the administration of the TLR9agonist, e.g., certain CpG ODN, and checkpoint inhibitor therapeuticagents as described above in further combination with other biologicallyactive ingredients (such as, but not limited to, a further and differentantineoplastic agent, a dendritic vaccine or other tumor vaccine). Insome embodiments, the checkpoint inhibitor is an antibody orantigen-binding fragment thereof. In some embodiments, the checkpointinhibitor is a bispecific antibody or bispecific antigen-bindingfragment thereof. However, in certain embodiments, “combination therapy”specifically excludes the administration of a dendritic cell or tumorvaccine.

II. CpG DNA

CpG oligonucleotides (CpG DNA; CpG ODN) contain specific sequences foundto elicit an immune response. These specific sequences are referred toas “immunostimulatory motifs”, and the oligonucleotides that containimmunostimulatory motifs are referred to as “immunostimulatoryoligonucleotide molecules” and equivalently, “immunostimulatoryoligonucleotides”. Immunostimulatory oligonucleotides include at leastone immunostimulatory motif, and preferably that motif is an internalmotif. The term “internal immunostimulatory motif” refers to theposition of the motif sequence within an oligonucleotide sequence whichis at least one nucleotide longer (at both the 5′ and 3′ ends) than themotif sequence.

CpG oligonucleotides include at least one unmethylated CpG dinucleotide.An oligonucleotide containing at least one unmethylated CpG dinucleotideis an oligonucleotide molecule which contains a cytosine-guaninedinucleotide sequence (i.e., “CpG DNA” or DNA containing a 5′ cytosinelinked by a phosphate bond to a 3′ guanine) and activates the immunesystem. The entire CpG oligonucleotide can be unmethylated or portionsmay be unmethylated, but at least the C of the 5′ CG 3′ must beunmethylated.

CpG ODN are generally about 8-100 nucleotides long. In certainembodiments, CpG ODN are about 8-50 nucleotides long, about 8-40nucleotides long, about 8-30 nucleotides long, about 8-24 nucleotideslong, about 8-20 nucleotides long, or about 8-16 nucleotides long.

By 2004, structure-activity relationship studies of CpG ODN had definedthree families with distinct structural and biological characteristics(Hartmann et al., Eur. J. Immunol. 2003, 33:1633-1641; Marshall et al.,J. Leukocyte Biol. 2003 73: 781-792; Vollmer et al., Eur. J. Immunol.2004 34:251-262). Typical B-class ODN have a completely phosphorothioatebackbone, do not form higher-ordered structures, and are strong B cellstimulators, inducing relatively high levels of IL-10 secretion, butinduce relatively little NK activity or IFN-α secretion (Krieg, 2002,and Krieg, unpublished observations). B-class CpG ODN induceimmune-suppressive counter-regulatory effects including not only thesecretion of IL-10, but also the expression of IDO, which can promotethe development of Treg cells in vitro (Moseman et al., J. Immunol. 2004173(7): 4433-4442; Chen et al., J. Immunol. 2008 181(8): 5396-5404). Therelevance of these in vitro data to in vivo tumor immunotherapy has beenuncertain, and has not delayed the clinical development of B-class ODN,but the present disclosure is based in part on a new discovery thatthese effects of B-class ODN will suppress anti-tumor immune responses,which can be avoided using other classes of CpG ODN that arestructurally designed not to activate the NF-κB pathway leading to IL-10secretion.

The phosphorothioate backbone used in B-class CpG ODN has multiplecomplex effects on the resulting immune response compared to that seenwith a CpG ODN with the same sequence but without a phosphorothioatebackbone. One very important effect of the phosphorothioate (PS)backbone is protection against nuclease degradation. CompletelyPS-modified ODN are nearly completely stable in serum and tissues for atleast 24 hr, whereas unmodified and unprotected ODN are degraded withina few minutes. In serum the major nuclease activity is a 3′ exonucleaseagainst which CpG ODN can be protected with just 1 or a few PS linkagesat the 3′ end of the ODN. But in tissues there also are 5′ exonucleasesas well as endonucleases, and these can degrade native DNA that is nototherwise protected. Native DNA can be protected against exonucleases bycircularization using techniques well described in the literature. See,for example, U.S. Pat. Nos. 8,017,591; 7,635,468; 7,074,772; 6,849,725;6,451,593; and 6,451,563; and U.S. Published Patent Application No.2003/0125279; the entire contents of all of which are herebyincorporated by reference. Alternatively or in addition, the native(i.e., otherwise unmodified and unprotected) ODN can be formulated innanoparticles or other formulations well known in the art to blocknuclease access to the ODN.

In general, native CpG DNA (phosphodiester) activates TLR9 in both Bcells and pDC. B cells produce cytokine and start to proliferate (thisis predominantly driven through NF-κB activation), but unless the TLR9stimulation is sustained, the proliferation is usually modest, andrelatively little stimulation of Ig secretion and class switchingoccurs. pDC are activated by native CpG DNA to secrete type I IFN and toexpress costimulatory receptors, but the magnitude of the stimulationdepends critically on the form of the DNA. In contrast to these effectsof native CpG DNA, B-class phosphorothioate CpG DNA provides a far morepowerful and sustained TLR9 signal for B cells, inducing them toproliferate strongly and leading to Ig secretion and class switching asreported in the literature. But the phosphorothioate backbone has a verydifferent effect on the TLR9-mediated pDC response, reducingsubstantially the IFN secretion (apparently through suppressingIRF7-mediated signaling), but usually still providing strong inductionof costimulatory molecule expression. Thus, for the present disclosure,the use of native DNA usually will provide higher type I IFN responsesand will be therapeutically effective as long as the native DNA isprotected from degradation. From 1 to 3 phosphorothioate modificationscan be added onto the 5′ and 3′ termini of native DNA to protect it fromnuclease degradation without diminishing the type I IFN response.

Early on in the development of CpG ODN for cancer immunotherapy, thoseskilled in the art generally believed that B-cell activation wasdesirable, and therefore focused development efforts on the B-class ODN.Indeed, perhaps B-cell activation is desirable for a tumor vaccine, inorder to drive the production of anti-tumor Ab, which are well known inthe field to be able to contribute to the anti-tumor response. Someearly human clinical trials employing intratumoral administration ofB-class CpG gave encouraging evidence of dendritic cell activation inthe tumor draining lymph nodes (e.g., Molenkamp B G et al., Clin CancerRes. 2007 13(10): 2961-2969). However, clinical responses to this localintratumoral therapy were quite limited, and studies of the totallymphocyte population in the draining lymph nodes showed an approximatetwo-fold increase in the release of IL-10 in CpG-treated patients (Table2 in Molenkamp et al.). Considering the negative effects of IL-10 fortumor immunotherapy, and the need for improved CpG ODN that do notinduce its production, or which induce a lower level of this production,the present disclosure further provides improved CpG ODN with reducedinduction of IL-10.

Nevertheless, it has now been discovered, in accordance with the presentdisclosure, that for intratumoral administration in particular, B cellactivation with the concomitant IL-10 and IDO induction, is undesirable,and perhaps deleterious. This is difficult or impossible to demonstrateusing mouse models because of the species-specific differences in theTLR9 expression and differences in the cytokine responses. The presentdisclosure is based on a new analysis of previously published andunpublished data on the human immune cell responses to various CpG ODN,together with a new analysis of the immune effects and deficiencies ofother cancer immunotherapies and XRT.

For cancer immunotherapy IL-10 can sometimes have positive effects(especially with systemic therapy, see for example Mumm and Oft,Bioessays 2013 35(7): 623-631), but IL-10 is generally considered tohave negative immune effects in the local tumor microenvironment,inhibiting immune rejection (reviewed in Sato et al., Immunol Res. 201151(2-3): 170-182). Thus, the present disclosure is based in part on thediscovery that B-class CpG ODN, which induce high levels of IL-10, arenot preferred for intra-tumoral therapy.

The B-class of CpG oligonucleotides is represented by the formula:

5′X₁CGX₂3′

wherein X₁ and X₂ are nucleotides. In some embodiments, X₁ may beadenine, guanine, or thymine and/or X₂ may be cytosine, adenine, orthymine.

The B-class of CpG oligonucleotides is also represented by the formula:

5′X₁X₂CGX₃X₄3′

wherein X₁, X₂, X₃, and X₄ are nucleotides. X₂ may be adenine, guanine,or thymine. X₃ may be cytosine, adenine, or thymine.

The B-class of CpG oligonucleotides also includes oligonucleotidesrepresented by at least the formula:

5′N₁X₁X₂CGX₃X₄N₂3′

wherein X₁, X₂, X₃, and X₄ are nucleotides and N is any nucleotide andN₁ and N₂ are oligonucleotide sequences composed of from about 0-25 N'seach. X₁X₂ may be a dinucleotide selected from the group consisting of:GpT, GpG, GpA, ApA, ApT, ApG, CpT, CpA, CpG, TpA, TpT, and TpG; and X₃X₄may be a dinucleotide selected from the group consisting of: TpT, ApT,TpG, ApG, CpG, TpC, ApC, CpC, TpA, ApA, and CpA.

The B-class of CpG oligonucleotides is disclosed in PCT Published PatentApplications PCT/US95/01570 and PCT/US97/19791, and U.S. Pat. No.6,194,388 B1 and U.S. Pat. No. 6,239,116 B1, issued Feb. 27, 2001 andMay 29, 2001 respectively.

In contrast to the B-class CpG ODN, A-class CpG ODN are potentactivators of natural killer cells and IFN-α secretion from plasmacytoiddendritic cells (pDC), but only weakly stimulate B cells, and inducevery little IL-10 secretion. Canonical A-class ODN contain polyG motifsat the 5′ and/or 3′ ends which are capable of forming complexhigher-ordered structures known as G-tetrads and a centralphosphodiester region containing one or more CpG motifs within aself-complementary palindrome (reviewed in (Krieg, 2006).

The A-class of CpG oligodeoxynucleotides is represented by the formula:

5′N₁N₂N₃3′

wherein N₁ comprises 0-20 guanosines, N₂ is from 4-40 bases in lengthand which contains at least 1 unmethylated CpG dinucleotide, and N₃comprises 3-20 guanosines. In preferred embodiments N₁ comprises between4-15 G and in some preferred embodiments it comprises 10 G. In somepreferred embodiments, N₂ comprises a palindrome (a self-complementaryDNA sequence, such as ACGT) that is from 4-20 bases in length. In someembodiments there are additional bases on the 5′ and/or 3′ side of thepalindrome within N₂, and in preferred embodiments these bases comprisea plurality of T. In some embodiments, some or all of the nucleotidescomprising N₁ and/or N₃ are linked by phosphorothioate internucleotidelinkages. In preferred embodiments the nucleotides comprising N₂ arelinked by phosphodiesters. In some embodiments all of the bases in theCpG-A ODN are linked by phosphodiesters.

In one embodiment, a CpG-A ODN is at least about 16 nucleotides inlength and includes a sequence represented by the formula:

5′X₁X₂X₃Pu₁Py₂CpG Pu₃Py₄X₄X₅X₆(W)_(M)(G)_(N)-3′

wherein the central CpG motif is unmethylated, Pu is a purinenucleotide, Py is a pyrimidine nucleotide, X and W are any nucleotide, Mis any integer from 0 to 20, and N is any integer from 4 to 20.

For example, U.S. Pat. Nos. 6,949,520 and 7,776,344 show that in certainpreferred embodiments the A-class CpG ODN has a sequence correspondingto any of the following:

(SEQ ID NO: 43) ggGGTCAACGTTGAgggggG; (SEQ ID NO: 44)tcgtcgttttgtcgttttgtcgtt; (SEQ ID NO: 45) ggggtcgtcgttttgggggg;(SEQ ID NO: 46) tcgtcgttttgtcgttttgggggg; (SEQ ID NO: 47)ggggtcgacgtcgagggggg; (SEQ ID NO: 48) ggggtcatcgatgagggggg;(SEQ ID NO: 49) ggGGGACGATCGTCgggggG; (SEQ ID NO: 50)gggggtcgtacgacgggggg; (SEQ ID NO: 51) ggGGGACGATATCGTCgggggG;(SEQ ID NO: 52) ggGGGACGACGTCGTCgggggG; (SEQ ID NO: 53)ggGGGACGAGCTGCTCgggggG; (SEQ ID NO: 54) ggGGGACGTACGTCgggggG;(SEQ ID NO: 55) ggGGGACGATCGTTGgggggG; (SEQ ID NO: 56)ggGGAACGATCGTCggggG; (SEQ ID NO: 57) ggGGGGACGATCGTCgggggG;(SEQ ID NO: 58) ggGGGACGATCGTCGgggggG; (SEQ ID NO: 59)ggGGGTCATCGATGAgggggG; (SEQ ID NO: 60) ggGGTCGTCGACGAgggggG;(SEQ ID NO: 61) ggGGTCGTTCGAACGAgggggG; (SEQ ID NO: 62)ggGGACGTTCGAACGTgggggG; (SEQ ID NO: 63) ggGGAACGACGTCGTTgggggG;(SEQ ID NO: 64) ggGGAACGTACGTCgggggG; (SEQ ID NO: 65)ggGGAACGTACGTACGTTgggggG; (SEQ ID NO: 66) ggGGTCACCGGTGAgggggG;(SEQ ID NO: 67) ggGGTCGACGTACGTCGAgggggG; (SEQ ID NO: 68)ggGGACCGGTACCGGTgggggG; (SEQ ID NO: 69) ggGTCGACGTCGAgggggG;(SEQ ID NO: 70) ggGGTCGACGTCGagggg; (SEQ ID NO: 71)ggGGAACGTTAACGTTgggggG; (SEQ ID NO: 72) ggGGACGTCGACGTggggG;(SEQ ID NO: 73) ggGGGTCGTTCGTTgggggG; (SEQ ID NO: 74)ggGACGATCGTCGgggggG; (SEQ ID NO: 75) ggGTCGTCGACGAggggggG;(SEQ ID NO: 76) ggTCGTCGACGAGgggggG; (SEQ ID NO: 77)ggGGACGATCGTCGgggggG; (SEQ ID NO: 78) ggGGTCGACGTCGACGTCGAGgggggG; and(SEQ ID NO: 79) ggGGACGACGTCGTGgggggG,wherein each lower case letter represents a nucleotide linked to its3′-adjacent nucleotide by a phosphorothioate (PS) linkage; and eachupper case letter represents a nucleotide linked to its 3′-adjacentnucleotide (if present) by a phosphodiester (PO) linkage, except thatthe 3′-terminal nucleotide is represented by an upper case letter sinceit has no 3′-adjacent nucleotide.

In certain more preferred embodiments the immunostimulatory nucleic acidhas a sequence corresponding to

(SEQ ID NO: 80) ggGGGACGAGCTCGTCgggggG; (SEQ ID NO: 58)ggGGGACGATCGTCGgggggG; (SEQ ID NO: 81) ggGGACGATCGAACGTgggggG;(SEQ ID NO: 78) ggGGTCGACGTCGACGTCGAGgggggG; or (SEQ ID NO: 79)ggGGACGACGTCGTGgggggG;wherein each lower case letter represents a nucleotide linked to its3′-adjacent nucleotide by a phosphorothioate (PS) linkage; and eachupper case letter represents a nucleotide linked to its 3′-adjacentnucleotide (if present) by a phosphodiester (PO) linkage, except thatthe 3′-terminal nucleotide is represented by an upper case letter sinceit has no 3′-adjacent nucleotide.

In certain embodiments, an A-class CpG ODN for use in accordance withthe methods of the instant invention has a sequence provided as:5′-GGGGGGGGGGGACGATCGTCGGGGGGGGGG-3′ (SEQ ID NO:82; also referred toherein as “G10”). Such oligonucleotide and formulations thereof usefulin accordance with the present disclosure are described inPCT/2015/067269, WO 2003/024481; US 2003/0099668; US 2012/0301499; WO2004/084940; U.S. Pat. No. 7,517,520; US 2010/0098722; WO 2007/068747;US 2007/0184068; U.S. Pat. No. 8,574,564; WO 2007/144150; U.S. Pat. No.8,541,559; WO 2008/073960; and U.S. Pat. No. 8,586,728, the entirecontents of each of which is incorporated herein by reference.

CpG-A oligonucleotides are also known in the art as D-type CpG asdefined by Klinman and colleagues, and as disclosed in U.S. Pat. Nos.7,521,063, 7,892,569, and US Appln. No. 2013/0012922, each of which areincorporated by reference in their entirety. Table 2 and SEQ ID NOs43-62 from US Appln. No. 2013/0012922 is particularly noted andincorporated by reference herein.

The structure of C-class ODN is typically based on a phosphorothioatebackbone, but is distinct in that the CpG motifs are followed by a 3′palindrome, which may form a duplex. C-class ODN are described in U.S.Pat. No. 7,566,703 to Krieg et al.; U.S. Pat. No. 8,198,251 to Vollmeret al.; and U.S. Pat. No. 8,834,900 to Krieg et al. The C-class CpG ODNhave immune properties intermediate between the A and B classes(Hartmann et al., 2003; Marshall et al., 2003; Marshall et al., 2005;Vollmer et al., 2004).

Examples of C-class ODN include:

(SEQ ID NO: 83) TCGTCGTTTTCGGCGCGCGCCG; (SEQ ID NO: 84)TCGTCGTTTTCGGCGGCCGCCG; (SEQ ID NO: 85) TCGTCGTTTTCGGCGCGCCGCG;(SEQ ID NO: 86) TCGTCGTTTTCGGCGCCGGCCG; (SEQ ID NO: 87)TCGTCGTTTTCGGCCCGCGCGG; (SEQ ID NO: 88) TCGTCGTTTTCGGCGCGCGCCGTTTTT;(SEQ ID NO: 89) TCCTGACGTTCGGCGCGCGCCG; (SEQ ID NO: 90)TZGTZGTTTTZGGZGZGZGZZG; (SEQ ID NO: 91) TCCTGACGTTCGGCGCGCGCCC;(SEQ ID NO: 92) TCGGCGCGCGCCGTCGTCGTTT; (SEQ ID NO: 93)TCGTCGTTTTCGGCGGCCGACG; (SEQ ID NO: 94) TCGTCGTTTTCGTCGGCCGCCG;(SEQ ID NO: 95) TCGTCGTTTTCGACGGCCGCCG; (SEQ ID NO: 96)TCGTCGTTTTCGGCGGCCGTCG; (SEQ ID NO: 97) TCGTCGTTTCGACGGCCGTCG;(SEQ ID NO: 98) TCGTCGTTTCGACGATCGTCG; (SEQ ID NO: 99)TCGTCGTTTCGACGTACGTCG; (SEQ ID NO: 100) TCGTCGCGACGGCCGTCG;(SEQ ID NO: 101) TCGTCGCGACGATCGTCG; (SEQ ID NO: 102)TCGTCGCGACGTACGTCG; (SEQ ID NO: 103) TCGTTTTTTTCGACGGCCGTCG;(SEQ ID NO: 104) TCGTTTTTTTCGACGATCGTCG; and (SEQ ID NO: 105)TCGTTTTTTTCGACGTACGTCG,wherein each Z is 5-methylcytosine.

According to certain embodiments the immunostimulatory nucleic acidincludes the sequence TCGGCGCGCGCCGTCGTCGTTT (SEQ ID NO:92).

The oligonucleotide may comprise 5′ T*T*T*C_G*T*C_G*T*T*T*C_G*T*C_G*T*T3′ (SEQ ID NO:106), wherein * represents a stabilized internucleotidelinkage. Optionally, when specifically stated, 5′ may refer to the free5′ end of the oligonucleotide and 3′ may refer to the free 3′ end of theoligonucleotide.

In some embodiments of the invention the oligonucleotide has one of thefollowing formulas:

(SEQ ID NO: 107) TCGTCGTTCGGCGCGCCG, (SEQ ID NO: 108)TCGTCGTCGTTCGGCGCGCGCCG, (SEQ ID NO: 109) TCGTCGACGATCGGCGCGCGCCG,(SEQ ID NO: 110) TTCGTCGTTTTGTCGTT, or  (SEQ ID NO: 106)TTTCGTCGTTTCGTCGTT.

In other embodiments of the invention the oligonucleotide has one of thefollowing formulas:

TCGTCGTC, CGTCGTCG, GTCGTCGT, TCGTCGTT, CGTCGTTC,GTCGTTCG, TCGTTCGG, CGTTCGGC, GTTCGGCG, TTCGGCGC,TCGGCGCG, CGGCGCGC, GGCGCGCG, GCGCGCGC, CGCGCGCC, or  GCGCGCCG.

In other embodiments of the invention the oligonucleotide has one of thefollowing formulas:

T*C_G*T*C_G*T*C, C_G*T*C_G*T*C_G, G*T*C G*T*C G*T,T*C_G*T*C_G*T*T, C_G*T*C_G*T*T*C, G*T*C_G*T*T*C_G,T*C_G*T*T*C_G*G, C_G*T*T*C_G*G*C, G*T*T*C_G*G*C*G,T*T*C_G*G*C*G*C, T*C_G*G*C*G*C_G, C_G*G*C*G*C_G*C,G*G*C*G*C_G*C*G, G*C*G*C_G*C*G*C,  C*G*C_G*C*G*C*C, or G*C_G*C*G*C*C*G,wherein * represents a stabilized internucleotide linkage.

In other embodiments of the invention an oligonucleotide comprising:T*C_G*T*C_G*T*C, wherein * represents a stabilized internucleotidelinkage and represents phosphodiester or phosphodiester-likeinternucleotide linkage is provided. Optionally the oligonucleotide maybe 5′ T*C_G*T*C_G*T*C_G*T*T*C_G*G*C*G*C_G*C*G*C*C 3′ (SEQ ID NO:111), 5′T*C_G*T*C_G*T*C_G*T*T*C_G*G*C*G*C 3′ (SEQ ID NO:112), or 5′T*C_G*T*C_G*T*C_G*T*T*C_G*G*C*G*C_G*C*G*C 3′ (SEQ ID NO:113) wherein 5′refers to the free 5′ end of the oligonucleotide and 3′ refers to thefree 3′ end of the oligonucleotide.

In other embodiments an oligonucleotide comprising: T*C_G*T*T*C_G*G,wherein * represents a stabilized internucleotide linkage and representsphosphodiester or phosphodiester-like internucleotide linkage isprovided. Optionally the oligonucleotide may be

(SEQ ID NO: 114) 5′ C_G*T*C_G*T*C_G*T*T*C_G*G*C*G*C_G*C*G*C*C*G 3′; (SEQ ID NO: 115) 5′ G*T*C_G*T*C_G*T*T*C_G*G*C*G*C_G*C*G*C*C*G 3′; (SEQ ID NO: 116) 5′ T*C_G*T*C_G*T*T*C_G*G*C*G*C_G*C*G*C*C*G 3′; (SEQ ID NO: 117) 5′ C G*T*C_G*T*T*C_G*G*C*G*C_G*C*G*C*C*G 3′; (SEQ ID NO: 118) 5′ G*T*C_G*T*T*C_G*G*C*G*C_G*C*G*C*C*G 3′;  or(SEQ ID NO: 119) 5′ T*C_G*T*T*C_G*G*C*G*C_G*C*G*C*C*G 3′,wherein 5′ refers to the free 5′ end of the oligonucleotide and 3′refers to the free 3′ end of the oligonucleotide.

More recently a new class of CpG oligo was identified with thestructural feature of two palindromes (vs the single palindrome in theC-class). See, e.g., U.S. Patent Application Pub. 2008/0045473, theentire content of which is incorporated herein by reference. Because ofthe two palindromes these P-class CpG ODN are able to form higher-orderconcatamers, which are hypothesized to interact with TLR9 in a differentmanner from the linear B-class ODN or duplex C-class ODN, with theobserved result that the P-class ODN induce higher levels of type I IFNcompared to C-class (or B-class), and substantially lower levels ofIL-10.

Examples of P-class ODN include:

(SEQ ID NO: 109) T*C-G*T*C-G*A*C-G*A*T*C-G*G*C*G*C-G*C*G*C*C*G;(SEQ ID NO: 120)T-C-G-T-C-G-A-C-G-A-T*T*T*T-A-C-G-A-C-G-T-C-G-T-T*T*T*T;(SEQ ID NO: 121) T-C-G-T-C-G-A-C-G-A-T-T-T-T-A-C-G-A-C-G-T-C-G-T-T-T-T; (SEQ ID NO: 122) T-C-G-T-C-G-A-C-G-A-A-C-G-A-C-G-T-C-G-T; (SEQ ID NO: 123) T-C-G-T-C-G-A-C-G-A-T*T*T*T-T-C-G-T-C-G-A-C-G-A-T*T*T; (SEQ ID NO: 123) T-C-G-T-C-G-A-C-G-A-T-T-T-T-T-C-G-T-C-G-A-C-G-A-T-T-T; (SEQ ID NO: 124) T-C-G-T-C-G-A-C-G-A-T-C-G-T-C-G-A-C-G-A; (SEQ ID NO: 125) C*G*C*G*C*G*C*G*C*G*C*G*C*G*C*G*C*G*C*G;(SEQ ID NO: 126) G*A*G*A*A*C*G*C*T*C*G*A*C*C*T*T*C*G*A*T*biot;(SEQ ID NO: 127) A*G*C*T*C*C*A*T*G*G*T*G*C*T*C*A*C*T*G; (SEQ ID NO: 128)T*C*T*C*C*C*A*G*C*G*T*G*C*G*C*C*A*T; (SEQ ID NO: 129)T*C*C*A*T*G*A*C*G*T*T*C*C*T*G*A*G*G*T*T; (SEQ ID NO: 130)T*C*C*A*G*G*A*C*T*T*C*T*C*T*C*A*G*G*T*T; (SEQ ID NO: 131)T*C*C*A*C*G*A*C*G*T*T*T*T*C*G*A*C*G*T*T; (SEQ ID NO: 132)T*C*G*T*C*G*T*T*T*T*G*A*C*G*T*T*T*T*G*A*C*G*T*T; (SEQ ID NO: 91)T*C*C*T*G*A*C*G*T*T*C*G*G*C*G*C*G*C*G*C*C*C; (SEQ ID NO: 133)T*C*G*C*G*T*G*C*G*T*T*T*T*G*T*C*G*T*T*T*T*G*A*C*G*T*T; (SEQ ID NO: 134)T*C*G*C*G*A*C*G*T*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 135)dig-C*C*G*G*C*C*G*G*C*C*G*G*C*C*G*G*C*C*G*G; (SEQ ID NO: 136)dig-C*G*C*G*C*G*C*G*C*G*C*G*C*G*C*G*C*G*C*G; (SEQ ID NO: 137)T*C*C*A*G*G*A*C*T*T*C*T*C*T*C*A*G*G*T*T*T*T*T*T; (SEQ ID NO: 138)G*T*G*C*T*C*G*A*G*G*A*T*G*C*G*C*T*T*C*G*C; (SEQ ID NO: 139)G*C*C*G*A*G*G*T*C*C*A*T*G*T*C*G*T*A*C*G*C; (SEQ ID NO: 133)T-C-G-C-G-T-G-C-G-T-T-T-T-G-T-C-G-T-T-T-T-G-A-C-G-T-T;  (SEQ ID NO: 140)A*C*C*G*A*T*A*C*C*G*G*T*G*C*C*G*G*T*G*A*C*G*G*C*A*C*C*A*C*G; (SEQ ID NO: 141)A*C*C*G*A*T*A*A*C*G*T*T*G*C*C*G*G*T*G*A*C*G*G*C*A*C*C*A*C*G;(SEQ ID NO: 142)A*C*C*G*A*T*G*A*C*G*T*C*G*C*C*G*G*T*G*A*C*G*G*C*A*C*C*A*C*G; (SEQ ID NO: 143) C*G*G*C*G*C*G*C*G*C*C*G*C*G*G*C*G*C*G*C*G*C*C*G;(SEQ ID NO: 144) T*C*G*A*T*C*G*T*T*T*T*T*C*G*T*G*C*G*T*T*T*T*T;(SEQ ID NO: 145) T*C*G*T*C*C*A*G*G*A*C*T*T*C*T*C*T*C*A*G*G*T*T;(SEQ ID NO: 146) T*C*G*T*C*G*T*C*C*A*G*G*A*C*T*T*C*T*C*T*C*A*G*G*T*T;(SEQ ID NO: 147) T*C*G*T*G*A*C*G*G*G*C*G*G*C*G*C*G*C*G*C*C*C;(SEQ ID NO: 148) A*C*G*A*C*G*T*C*G*T*tC*G*G*C*G*G*C*C*G*C*C*G;(SEQ ID NO: 149) G*G*G-G-A-C-G-A-C-G-T-C-G-T-G-C*G*G*C*G*G*C*C*G*C*C*G;(SEQ ID NO: 149) G*G*G*G*A*C*G*A*C*G*T*C*G*T*G*C*G*G*C*G*G*C*C*G*C*C*G; (SEQ ID NO: 150)C*C-A*C-G*A*C-G*T*C-G*T*C-G-A-A-G*A*C-G*A*C-G*T*C-G*T-G*G;(SEQ ID NO: 151) C*T-G*C*A*G-C*T-G-C*A*G-C*T-G-C*A*G-C*T-G*C*A*G;(SEQ ID NO: 152) C*G*G-C*C-G*C*T-G*C*A-G-C*G-G*C*C-G*C*T-G*C*A*G;(SEQ ID NO: 153) C*A*T*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T; (SEQ ID NO: 154)A*T*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T; (SEQ ID NO: 155)T*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T; (SEQ ID NO: 156)A*T*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T*G*T; (SEQ ID NO: 157)T*C*C*A*T*G*A*C-G-T*T*T*T*T*G*A*T*G*T*T; (SEQ ID NO: 157)T*C*C*A*T*G*A-C-G-T*T*T*T*T*G*A*T*G*T*T; (SEQ ID NO: 157)T*C*C*A*T*G*A*C*G*T*T*T*T*T*G*A*T-G-T*T; (SEQ ID NO: 157)T*C*C*A*T*G*A*C-G-T*T*T*T*T*G*A*T-G*T*T; (SEQ ID NO: 157)T*C*C*A*T*G*A-C-G-T*T*T*T*T*G*A*T-G*T*T; (SEQ ID NO: 156)A*T*G*A*C-G*T*T*T*T*T*G*A*T*G*T*T*G*T; (SEQ ID NO: 156)A*T*G*A*C*G*T*T*T*T*T*G*A*T-G*T*T*G*T; (SEQ ID NO: 156)A*T*G*A*C-G*T*T*T*T*T*G*A*T-G*T*T*G*T; (SEQ ID NO: 156)A*T*G*A-C-G-T*T*T*T*T*G*A-T-G-T*T*G*T; (SEQ ID NO: 158)T*C*C*A*T*G*C*G*T*T*T*T*T*G*A*A*T*G*T*T; (SEQ ID NO: 159)T*C*C*A*T*G*A*C*G*T*C*T*T*T*G*A*T*G*T*C; (SEQ ID NO: 160)A-C-G-A-C-G-T-C-G-T-T-C-A-C-G-A-C-G-T-C-G-T-chol;  (SEQ ID NO: 161)A-C-G-A-C-G-T-C-G-T-G-G-C-C-A-C-G-A-C-G-T-C-G-T-D-D-D;  (SEQ ID NO: 162)A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D;  (SEQ ID NO: 163)D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D; (SEQ ID NO: 164)D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-chol; (SEQ ID NO: 165)G*G*G-A-C-G-A-C-G-T-C-G-T-G*G*C*C-A-C-G-A-C-G-T-C-G-T-C*C*C;(SEQ ID NO: 166) C*C*C-A-C-G-A-C-G-T-C-G-T-G*G*G;  (SEQ ID NO: 167)C*C*C*V-A-C-G-A-C-G-T-C-G-T-G*G*G*G;  (SEQ ID NO: 144)T*C*G*A*T*C*G*T*T*T*T-T-C-G*T*G*C*G*T*T*T*T*T; (SEQ ID NO: 144)T*C*G*A*T*C*G*T*T*T-T-T-C-G-T*G*C*G*T*T*T*T*T; (SEQ ID NO: 144)T*C*G*A*T*C*G*T*T-T-T-T-C-G-T-G*C*G*T*T*T*T*T;  (SEQ ID NO: 144)T*C*G*A*T*C*G-T-T-T-T-C*G*T*G*C*G*T*T*T*T*T;  (SEQ ID NO: 168)A*T-G*A*C-G*T*T*T*T*T-G*A*C-G*T*T; (SEQ ID NO: 169)A*C-G*A*C-G*T*T*T*T*T-G*A*T-G*T*T; (SEQ ID NO: 326)A*C-G*A*C-G*T*T*T*T*C-G*A*C-G*T*T; (SEQ ID NO: 170)A*T-G*A*T-G*T*T*T*T*T-G*A*T-G*T*T; (SEQ ID NO: 171)A*T-G*A*C-G*T*T*T*T*G-A*T*G-T*T; (SEQ ID NO: 172)A*T-G*A*C-G*T*T*T*G*T-G*A*T-G*T*T; (SEQ ID NO: 173)T*T-G*A*C-G*T*T*T*T*T-G*A*T-G*T*T; (SEQ ID NO: 170)A*T-G*A*T-G*T*T*T*T*T-G*A*T-G*T*T; (SEQ ID NO: 174)A*T-G*A*G-C*T*T*T*T*G-T*A*T-G*T*T; (SEQ ID NO: 175)T*C*G*A*C*G*T*T*T*T*C*G*G*C*G*G*C*C*G*C*C*G; (SEQ ID NO: 176)T*C*C*T*G*A*C*G*T*T*T*T*C*G*G*C*G*G*C*C*G*C*C*G; (SEQ ID NO: 177)T*C*C*T*G*A*C*G*T*T*C*G*G*C*G*G*C*C*G*C*C*G; (SEQ ID NO: 178)T*C*C*A*T*G*A*C*G*T*T*C*G*G*C*G*C*G*C*G*C*C*C; (SEQ ID NO: 179)T*C*C*T*G*A*C*G*T*T*C*G*G*C*G*C*G*C*G*C*C; (SEQ ID NO: 180)T*C*G*A*C*G*T*T*T-T-G-G-C*G*C*G*C*G*C*C*G; (SEQ ID NO: 175)T*C*G*A*C*G*T*T*T-T-C-G-G-C*G*G*C*C*G*C*C*G; (SEQ ID NO: 181)T*C*G*A*C*G*T*C*G-A-C-G-T-T-A-G-G-G-T-T-A*G*G*G; (SEQ ID NO: 182)A*C*G*A*C*G*T*C*G-T-T-A-G-G-G-T-T-A*G*G*G; (SEQ ID NO: 183)G*T*C-G*G*C-G*T*T-G*A*C; (SEQ ID NO: 184)A-C-G-A-C-G-T-C-G-T-C-G-D-D-D-D-C-G-G-C-C-G-C-C-G; (SEQ ID NO: 184)A-C-G-A-C-G-T-C-G-T-C-G-D-D-D-D*C*G*G*C*C*G*C*C*G; (SEQ ID NO: 185)T-C-G-T-C-G-A*C*G*A*C*G*T*C*G*T*C*G; (SEQ ID NO: 186)T-C-G-T-C-G-A-C-G-A-C-G-T-C-G-T-C-G-D-D-D-D; (SEQ ID NO: 187)A-C-G-A-C-G-T-C-G-T-T*T*T*T-A-C-G-A-C-G-T-C-G-T-teg;  (SEQ ID NO: 162)A*C*G*A*C*G*T*C*G*T*D*D*D*D*A*C*G*A*C*G*T*C*G*T*D*D*D; (SEQ ID NO: 163)D*D*D*A*C*G*A*C*G*T*C*G*T*D*D*D*D*A*C*G*A*C*G*T*C*G*T*D*D*D;(SEQ ID NO: 188) A-C-G-A-C-G-T-C-G-T-T*T*T*T-A-C-G-A-C-G-T-C-G-T-D-D-D;(SEQ ID NO: 189) A-C-G-A-C-G-T-C-G-T-T*T*T*T-A-C-G-A-C-G-T-C-G-T-T*T*T;(SEQ ID NO: 189) A*C-G-A-C-G-T-C-G-T-T*T*T*T-A-C-G-A-C-G-T-C-G-T-T*T*T;(SEQ ID NO: 190) A*C-G-A-C-G-T-C-G-T-T*T*T*T-A-C-G-A-C-G-T-C-G*T;(SEQ ID NO: 191) A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-L;(SEQ ID NO: 192) A-C-G-A-C-G-T-C-G-T-L-A-C-G-A-C-G-T-C-G-T-L;(SEQ ID NO: 193) A-C-G-A-C-G-T-C-G-T-teg-teg-A-C-G-A-C-G-T-C-G-T-teg;(SEQ ID NO: 194) C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-D-D-D;(SEQ ID NO: 195) A-C-G-A-C-G-T-C-G-D-D-D-D-C-G-A-C-G-T-C-G-T-D-D-D;(SEQ ID NO: 196) C-G-A-C-G-T-C-G-D-D-D-D-C-G-A-C-G-T-C-G-D-D-D;(SEQ ID NO: 197) T-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-A-D-D-D;(SEQ ID NO: 198) A-C-G-T-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-A-C-G-T-D-D-D;(SEQ ID NO: 199) T-C-G-T-C-G-A-C-G-T-D-D-D-D-A-C-G-T-C-G-A-C-G-A-D-D-D;(SEQ ID NO: 200) T-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D;(SEQ ID NO: 201) A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-T-C-G-T-C-G-T-D-D-D;(SEQ ID NO: 202) A-C-G-A-C-G-T-T-D-D-D-D-A-A-C-G-T-C-G-T-D-D-D;(SEQ ID NO: 203) A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-D-D-D;(SEQ ID NO: 204) G-G-C-G-G-C-C-G-D-D-D-D-C-G-G-C-C-G-C-C-D-D-D;(SEQ ID NO: 205) G-C-G-G-C-C-G-G-D-D-D-D-C-C-G-G-C-C-G-C-D-D-D;(SEQ ID NO: 206) A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D;(SEQ ID NO: 207) D-A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D;(SEQ ID NO: 208) A*C-G-A-C-G-T-C-G-T-C-G-A-A-G-A-C-G-AC-G-T-C-G-T-D-D-T;(SEQ ID NO: 209)T*C-G-A-C-G-T-C-G-T-C-G-A-A-G-A-C-G-T-C-G-T-C-G-T-D-D-T;(SEQ ID NO: 150)C*C*A-C-G-A-C-G-T-C-G-T=C-G-A-A-G-A-C-G-A-C-G=T-C-G-T*G*G;(SEQ ID NO: 210) T*C*C*A*D*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T;(SEQ ID NO: 211) T*C*C*A*T*G*A*C*G*T*T*D*T*T*G*A*T*G*T*T;(SEQ ID NO: 212) T*C*C*A*J*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T;(SEQ ID NO: 213) T*C*C*A*T*G*A*C*G*T*T*J*T*T*G*A*T*G*T*T;(SEQ ID NO: 214) T*C*C*A*T*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T*Cy3;(SEQ ID NO: 215) J*J*J*J*J*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T;(SEQ ID NO: 216) T*C*C*A*J*G*A*C*G*T*T*J*T*T*G*A*T*G*T*T;(SEQ ID NO: 217) T*C*C*A*D*G*A*C*G*T*T*D*T*T*G*A*T*G*T*T;(SEQ ID NO: 218)A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D-rU;(SEQ ID NO: 219)A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D-rG;(SEQ ID NO: 220)A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-DrA;(SEQ ID NO: 221)D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D-rU;(SEQ ID NO: 222)A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D-rA-rA-rA-rA;(SEQ ID NO: 223) T*C*G*A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T;(SEQ ID NO: 224)T-T-T-A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-DrU;(T*C-G-A-C-G-T-C-G-T-)(vitE-)double-teg; (SEQ ID NO: 175)T*C*G*A*C-G*T*T*T*T*C-G*G*C*G*G*C*C-G*C*C*G; (SEQ ID NO: 180)T*C*G*A*C-G*T*T*T*T*C-G*G*C*G*C*G*C-G*C*C*G; (SEQ ID NO: 134)T*C-G*C-G*A*C-G*T*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 134)T*C*G*C-G*A*C*G*T*T*C-G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 134)T*C*G*C-G*A*C*G*T*T*C*G*G*C-G*C*G*C*G*C*C*G; (SEQ ID NO: 134)T*C*G*C-G*A*C*G*T*T*C*G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 134)T*C*G*C*G*A*C-G*T*T*C*G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 134)T*C*G*C*G*A*C-G*T*T*C*G*G*C-G*C*G*C*G*C*C*G; (SEQ ID NO: 134)T*C*G*C-G*A*C*G*T*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 134)T*C*G*C*G*A*C-G*T*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 225)T*C*G*C*G*A*C-G*T*T*C*G*C*G*C-G*C*G*C*G; (SEQ ID NO: 226)D*C*C*A*T*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T; (SEQ ID NO: 227)T*D*C*A*T*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T; (SEQ ID NO: 228)T*C*D*A*T*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T; (SEQ ID NO: 229)T*C*C*D*T*G*A*C*G*T*T*T*T*T*G*A*T*G*T*T; (SEQ ID NO: 230)T*C*C*A*T*G*A*C*G*T*T*T*T*D*G*A*T*G*T*T; (SEQ ID NO: 231)T*C*C*A*T*G*A*C*G*T*T*T*D*T*G*A*T*G*T*T; (SEQ ID NO: 232)T*C*G*A*A*C-G*T*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 233)T*C*G*T*C*G*A*A*C-G*T*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 234)T*C*G*T*C*G*A*A*C-G*T*T*C*G*G*C*G*C*T*G*C*G*C*C*G; (SEQ ID NO: 235)T*C*G*C*G*A*C-G*T*T*C*G*T*T*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 236)T*A*C*G*T*C-G*T*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 237)T*T*C*G*C*G*A*C-G*T*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 238)T*C*G*G*C*G*C*G*C*G*C*C-G*T*C*G*C*G*A*C*G*T; (SEQ ID NO: 239)T*A*G*C-G*T*G*C-G*T*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 240)T*A*G*C-G*A*G*C-G*T*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 241)T*T*G*C-G*A*G*C-G*T*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 242)A*T*G*C-G*T*G*C-G*T*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 243)T*T*A*C-G*T*G*C-G*T*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 244)T*T*G*C-A*T*G*C-G*T*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 245)T*T*G*C-G*T*A*C-G*T*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 246)T*T*G*C-G*T*G*C-A*T*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 247)T*T*G*C-G*T*G*C-G*A*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 248)T*T*G*C-G*C*G*C-G*T*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 249)T*T*G*C-G*T*G*C-G*C*T*T*T*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 250)T*T*G*C-G*T*G*C-G*T*T*T*C*G*A*C-G*T*T*T*T*T*T*T; (SEQ ID NO: 234)T*C*G*T*C-G*A*A*C*G*T*T*C-G*G*C*G*C*T*G*C*G*C*C*G; (SEQ ID NO: 234)T*C*G*T*C-G*A*A*C*G*T*T*C-G*G*C-G*C*T*G*C*G*C*C*G; (SEQ ID NO: 234)T*C*G*T*C-G*A*A*C*G*T*T*C-G*G*C*G*C*T*G*C-G*C*C*G; (SEQ ID NO: 234)T*C*G*T*C*G*A*A*C-G*T*T*C*G*G*C-G*C*T*G*C*G*C*C*G; (SEQ ID NO: 251)T*C*G*T*C-G*G*A*C*G*T*T*C-G*G*C*G*C*T*G*C*G*C*C*G; (SEQ ID NO: 235)T*C*G*C*G*A*C-G*T*T*C*G*T*T*G*C-G*C*G*C*G*C*C*G; (SEQ ID NO: 252)T*G*G*C-G*A*C*G*T*T*C-G*T*T*G*C-G*C*G*C*G*C*C*G; (SEQ ID NO: 235)T*C-G*C*G*A*C*G*T*T*C-G*T*T*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 253)T*C*G*C*G*A*C-G*T*T*T*T*G*C*G*C-G*C*G*C; (SEQ ID NO: 254)T*C*G*C*G*A*C-G*T*C*G*T*T*G*C-G*C*G*C*G*C*C*G; (SEQ ID NO: 255)T*C*G*C*G*A*C-G*T*T*C*G*A*A*G*C-G*C*G*C*G*C*C*G; (SEQ ID NO: 256)T*C*G*C*G*A*C-G*A*A*C*G*T*T*G*C-G*C*G*C*G*C*C*G; (SEQ ID NO: 257)T-C-G-A-C-G-T-C-G-T-D-D-D-D-T-C-G-A-C-G-T-C-G-T-D-D-D; (SEQ ID NO: 258)T*C*G*T*C*G*T*T*A*G*C*T*C*G*T*T*A*G*C*T*C*G*T*T; (SEQ ID NO: 259)T*C*G*T*C*G*T*T*A*C*G*T*A*A*T*T*A*C*G*T*C*G*T*T; (SEQ ID NO: 260)T*C*G*T*C*G*T*T*A*C*G*T*C*G*T*T*A*C*G*T*A*A*T*T; (SEQ ID NO: 261)T*C*G*T*C*G*T*T*A*C*G*T*A*A*T*T*A*C*G*T*A*A*T*T; (SEQ ID NO: 262)T*C*G*A*C*G*T*C*G-A-C*G*T*G*A*C*G*G*G; (T-C-G-A-C-G-T-C-G-T-T)2doub-but;(T-C-G-A-C-G-T-C-G-T-T)2doub-chol; (T-C-G-A-C-G-T-C-G-T-T-T)2doub-chol;T-C-G-A-C-G-T-C-G-T-T-T-chol-T-T-C-G-A-C-G-T-C-G-T-T-but;(SEQ ID NO: 263) T*C*G*C-G*A*C*G*T*T*C-G*G*C*G*C-G*C*T*G*C*C*G;(SEQ ID NO: 264) T*C*G*C-G*A*C*G*T*T*C-G*G*C*G*C-G*T*C*G*C*C*G;(SEQ ID NO: 265) T*C*G*C-G*A*C*G*T*T*C-G*G*C*G*G*C-T*C*G*C*C*G;(SEQ ID NO: 264) T*C*G*C*G-A*C*G*T*T*C-G*G*C*G*C-G*T*C*G*C*C*G;(SEQ ID NO: 265) T*C*G*C*G-A*C*G*T*T*C-G*G*C*G*G*C-T*C*G*C*C*G;(SEQ ID NO: 264) T*C*G-C*G*A*C*G*T*T*C-G*G*C*G*C-G*T*C*G*C*C*G;(SEQ ID NO: 265) T*C*G-C*G*A*C*G*T*T*C-G*G*C*G*G*C-T*C*G*C*C*G;(SEQ ID NO: 266) (T-C-G-A-C-G-T-C-G-T-)(vitE-); (SEQ ID NO: 262)T*C-G*A*C-G*T*C-G*A*C*G*T*G*A*C*G*G*G; (SEQ ID NO: 262)T*C*G*A*C*G*T*C*G*A*C*G*T*G*A*C*G*G*G; (SEQ ID NO: 267)T*C*G*A*C*G*T*C*G*A*C*G*T*G*A*C*G*T*C; (SEQ ID NO: 268)T*C*G*A*C*G*T*C*G*A*C*G*T*G*A*C*G; (SEQ ID NO: 269)(T-C-G-A-C-G-T-C-G-A-)(vitE-); (SEQ ID NO: 270)T*C*G*T*C*G*T*T*A*C*G*T*A*A*C*T*A*C*G*T*C*G*T*T; (SEQ ID NO: 550)T*C*G*T*C*G*T*T*A*C*G*T*A*A*C*G*A*C*G*T*C*G*T*T; (SEQ ID NO: 271)T*C*G*T*C*G*T*T*A*C*G*T*A*A*C*G*A*C*G*A*C*G*T*T; (SEQ ID NO: 272)T*C*G*T*C*G*T*T*A*G*C*T*A*A*T*T*A*G*C*T*C*G*T*T; (SEQ ID NO: 273)T*C*G*T*C*G*T*T*A*C*G*T*A*A*T*T*A*G*C*T*C*G*T*T; (SEQ ID NO: 274)C*C*C*A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 275)G*C*C*A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 276)A*C*C*A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 277)T*G*G*A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 278)T*T*T*A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 279)T*A*A*A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 280)C*C*A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 281)C*A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 282)A*T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 283)T*G*A*C*G*T*T*C*C*T*G*A*C*G*T*T; (SEQ ID NO: 284)T-C-G-A-C-G-T-C-G-A-D-D-D-D-T-C-G-A-C-G-T-C-G-A-chol; (SEQ ID NO: 285)teg-iA-iG-iC-iT-iG-iC-iA-iG-iC-iT-D-D-D-D-T-C-G-A-C-G-A-chol;(SEQ ID NO: 286) T*C-G*C-G*A*C-G*T*T*C-G*G*G*C-G*C-G*C*C-G;(SEQ ID NO: 287) T*C-G*T*C-G*A*C-G*T*T*C-G*G*C*G*C-G*C*G*C*C*G;(SEQ ID NO: 288) T*C-G*G*A*C-G*T*T*C-G*G*C*G*C-G*C*G*C*C*G;(SEQ ID NO: 289) T*C-G*G*A*C-G*T*T*C-G*G*C*G*C*G*C*C*G; (SEQ ID NO: 290)T*C-G*C-G*A*C-G*T*T*C-G*G*C*G*C*G*C*C*G; (SEQ ID NO: 225)T*C-G*C-G*AC-G*T*T*C-G*C-G*C-G*C-G*C-G; (SEQ ID NO: 291)T*C-G*A*C-G*T*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 292)T*C-G*A*C-G*T*T*C-G*G*C*G*C*G*C*C*G; (SEQ ID NO: 293)T*C-G*C-G*A*C-G*T*T*C-G*G*C*G*C*C*G; (SEQ ID NO: 294)T*C-G*C-G*A*C-G*T*T*C-G*G*C*C*G; (SEQ ID NO: 295)T*C-G*A*C-G*T*T*C-G*G*C*G*C*C*G; (SEQ ID NO: 296)T*C-G*T*C-G*A*C-G*T*T*C-G*G*C*G-G*G*C*C*G; (SEQ ID NO: 297)T*C-G*T*C-G*A*C-G*T*T*C-G*G*G*C-G*C*C*G; (SEQ ID NO: 298)T*C-G*A*C-G*A*C-G*T*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 299)T*C-G*A*C-G*T*C-G*T*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 109)T*C-G*T*C-G*A*C-G*A*T*C-G*G*C*G*C*G-C*G*C*C*G; (SEQ ID NO: 109)T*C-G*T*C-G*A*C-G*A*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 300)T*C-G*T*C-G*A*C-G*T*T*C-G*C*C*G*C-G*C*G*G*C*G; (SEQ ID NO: 301)T*C-G*T*C-G*A*C-G*T*T*C-G*G*C*G*C*C-G*T*G*C*C*G; (SEQ ID NO: 302)T*C-G*T*C-G*A*C-G*T*T*C-G*A*C*T*C-G*A*G*T*C*G; (SEQ ID NO: 271)T*C-G*T*C-G*T*T*A*C-G*T*A*A*C-G*A*C*G*A*C-G*T*T; (SEQ ID NO: 271)T*C*G*T*C-G*T*T*A*C-G*T*A*A*C-G*A*C*G*A*C*G*T*T; (SEQ ID NO: 303)T*C*G*A*C*G*T*C*G*A*C*G*T*G*A*C*G*T*T; (SEQ ID NO: 304)T*C*G*T*C*G*A*C*G*T*T*C*G*G*C*G*C*G*C*C*G; (SEQ ID NO: 109)T*C*G*T*C*G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 305)A-C-G-A-C-G-T-C-G-T-D-D-D-D-A-C-G-A-C-G-T-C-G-T-D-D-D-irU;(SEQ ID NO: 306) T*C-G*T*C-G*A*C-G*A*T*C-G*G*G*C*G*C*C-G*T*G*C*C*G;(SEQ ID NO: 307) T*C-G*T*C-G*A*C-G*A*T*C-G*G*C*G*C*C-G*T*G*C*C*G;(SEQ ID NO: 308) T*C-G*T*C-G*A*C-G*A*C-G*G*C*G*C*C-G*T*G*C*C*G;(SEQ ID NO: 307) T*C*G*T*C*G*A*C*G*A*T*C*G*G*C*G*C*C*G*T*G*C*C*G;(SEQ ID NO: 307) T*C*G*T*C-G*A*C-G*A*T*C-G*G*C*G*C*C-G*T*G*C*C*G;(SEQ ID NO: 307) T*C*G*T*C-G*A*C*G*A*T*C-G*G*C*G*C*C-G*T*G*C*C*G;(SEQ ID NO: 307) T*C*G*T*C*G*A*C*G*A-T-C*G*G*C*G*C*C*G*T*G*C*C*G;(SEQ ID NO: 109) T*C*G*T*C-G*A*C-G*A*T*C-G*G*C*G*C-G*C*G*C*C*G;(SEQ ID NO: 109) T*C*G*T*C-G*A*C*G*A*T*C-G*G*C*G*C-G*C*G*C*C*G;(SEQ ID NO: 109) T*C*G*T*C*G*A*C*G*A-T-C*G*G*C*G*C*G*C*G*C*C*G;(SEQ ID NO: 303) T*C*G*A*C*G*T*C*G-A-C*G*T*G*A*C*G*T*T; (SEQ ID NO: 303)T*C*G*A*C-G*T*C*G*A*C-G*T*G*A*C*G*T*T; (SEQ ID NO: 303)T*C*G*A*C-G*T*C*G*A*C*G*TG*A*C*G*T*T; (SEQ ID NO: 309)T*C*G*T*C-G*A*C*G*A*C-G*T*G*T*C*G*A*T; (SEQ ID NO: 303)T*C*G*A*C*G-T*C*G*A*C*G-T*G*A*C*G*T*T; (SEQ ID NO: 303)T*C*G*A-C*G*T*C*G-A*C*G*T*G-A*C*G*T*T; (SEQ ID NO: 307)T*C*G*T*C*G*A-C*G*A*T*C*G*G*C*G-C*C*G*T*G*C*C*G; (SEQ ID NO: 310)T*C*G*T*C*G*A-C*G*A*C*G*G*C*G*C-C*G*T*G*C*C*G*T; (SEQ ID NO: 310)T*C*G*T*C*G*A*C-G*A*C*G*G*C*G*C*C-G*T*G*C*C*G*T; (SEQ ID NO: 311)T*C*G*T*C-G*A*C-G*A*T*C-G*G*C*G*G*C-G*T*G*C*C*G*T; (SEQ ID NO: 312)T*C-G*T*C-G*A*C-G*T*T*C-G*G*C*G*C*C-G*T*G*C*C*G*T; (SEQ ID NO: 313)T*C-G*T*C-G*T*C-G*G*C*G*C*C*-G*T*G*C*C*G*T; (SEQ ID NO: 314)T*C-G*T*C-G*A*C-G*C-G*G*C*G*C*C-G*T*G*C*C*G*T; (SEQ ID NO: 314)T*C*G*T*C*G*A-C*G*C*G*G*C*G-C*C*G*T*G*C*C*G*T; (SEQ ID NO: 315)T*C*G*T*C-G*A*C*G*A-A*G*T*C-G*A*C*G*A*T; (SEQ ID NO: 316)T*C*G*T*C-G*A*C*G*A*G*A-A*T*C*G*T*C-G*A*C*G*A*T; (SEQ ID NO: 317)T*C*G*T*C-G*T*A*C-G*G*C*G*C*C-G*T*G*C*C*G*T; (SEQ ID NO: 307)T*C*G*T*C*G*A*C-G*A*T*C*G*G*C-G*C*C*G*T*G*C*C*G; (SEQ ID NO: 307)T*C*G*T*C*G*A-C*G*A*T*C*G*G*C*G-C*C*G*T*G*C*C*G; (SEQ ID NO: 307)T*C*G*T*C*G*A-C*G*A*T*C*G-G*C*G*C-C*G*T*G*C*C*G; (SEQ ID NO: 310)T*C*G*T*C*G*A-C*G*A*C*G*G*C*G*C-C*G*T*G*C*C*G*T; (SEQ ID NO: 318)T*C*G*T*C-G*A*C-G*A*T*C-G*G*C*G*C*C-G*T*G*C*C*G*T; (SEQ ID NO: 318)T*C*G*T*C*G*A-C*G*A*T*C*G*G*C*G-C*C*G*T*G*C*C*G*T; (SEQ ID NO: 310)T*C*G*T*C*G*A*C-G*A*C*G*G*C*G*C-C*G*T*G*C*C*G*T; (SEQ ID NO: 312)T*C-G*T*C-G*A*C-G*T*T*C-G*G*C*G*C*C-G*T*G*C*C*G*T; (SEQ ID NO: 313)T*C-G*T*C-G*A*C-G*T*C-G*G*C*G*C*C-G*T*G*C*C*G*T; (SEQ ID NO: 315)T*C*G*T*C-G*A*C*G*A-A*G*T*C-G*A*C*G*A*T; (SEQ ID NO: 316)T*C*G*T*C-G*A*C*G*A*G*A-A*T*C*G*T*C-G*A*C*G*A*T; (SEQ ID NO: 319)T*C*G*T*C-G*A*C*G*A*C-G*T*G*T*C*G*A*T; (SEQ ID NO: 320)T*C*G*A*C-G*T*C*G*A-A*G*A*C-G*T*C*G*A*T; (SEQ ID NO: 321)T*C*G*A*C-G*T*C*G*A*G*A-A*T*C*G*A*C-G*T*C*G*A*T; (SEQ ID NO: 322)T*C*G*T*C-G*A*C-G*A*C*G*G*C*G-A*A*G*C*C*G; (SEQ ID NO: 323)T*C*G*T*C-G*A*C-G*A*C*G*G*C*G-A*A*G*C*C*G*T; (SEQ ID NO: 309)T*C*G*T*C*G-A*C*G*A*C*G-T*G*T*C*G*A*T; (SEQ ID NO: 309)T*C*G*T*C*G*A*C*G*A*C*G*T*G*T*C*G*A*T; (SEQ ID NO: 324)T*C*G*A*C-G*T*C*G*A*C-G*T*G*A*C*G-T*T*G*T; (SEQ ID NO: 325)T*C+21G*T*C-G*A*C-G*A*T*C-G*G*C*G*C-G*C*G*C*C*G-but; (SEQ ID NO: 325)T*C-G*T*C<G*A*C-G*A*T*C-G*G*C*G*C-G*C*G*C*C*G-but; (SEQ ID NO: 327)T*C-G*T*C-G*A*C*G*A*T*C-G*G*C*G*C-G*C*G*C*C*C*G-iT; (SEQ ID NO: 328)iT-T*C-G*T*C-G*A*C*G*A*T*C-G*G*C*G*C-G*C*G*C*C*C*G-iT; (SEQ ID NO: 329)T*C-G*T*C-G*A*C-G*A*T*C-G*A*C*G*C-G*C*G*T*C*G; (SEQ ID NO: 330)T*C-G*T*C-G*A*C-G*A*T*C-A*A*C*G*C-G*C*G*T*T*G; (SEQ ID NO: 331)T*C-G*T*C-G*A*C-G*A*T*C-G*G*C*A*C-G*T*G*C*C*G (SEQ ID NO: 332)T*C-G*T*C-G*A*C-G*A*T*C-G*G*C*A*T-A*T*G*C*C*G; (SEQ ID NO: 333)T*C-G*T*C-G*A*C-G*A*T*G-C*C*G*C*G-C*G*C*G*G*C; (SEQ ID NO: 333)T*C*G*T*C*G*A*C*G*A*T*G*C*C*G*C*G*C*G*C*G*G*C; (SEQ ID NO: 333)T*C-G*T*C*G*A*C*G*A*T*G*C*C*G*C*G*C*G*C*G*G*C; (SEQ ID NO: 333)T*C*G*T*C-G*A*C*G*A*T*G*C*C*G*C*G*C*G*C*G*G*C; (SEQ ID NO: 334)T*C-G*T*C*G*A*C*G*A*T*G*C*C*G*C*G*C*T*G*C*G*G*C; (SEQ ID NO: 335)T*C-G*T*C*G*T*A*C*G*A*T*G*C*C*G*C*G*C*G*C*G*G*C; (SEQ ID NO: 336)T*C-G*T*C*G*T*A*C*G*A*T*G*C*C*G*C*G*C*T*G*C*G*G*C; (SEQ ID NO: 333)T*C*G*T*C*G*A*C*G*A*T-G*C*C*G*C*G*C*G*C*G*G*C; (SEQ ID NO: 333)T*C*G*T*C*G*A*C*G*A*T-G-C*C*G*C*G*C*G*C*G*G*C; (SEQ ID NO: 337)T*C*G*T*C-G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G-iT; (SEQ ID NO: 337)T*C-G*T*C*G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G-iT; (SEQ ID NO: 337)T*C*G*T*C*G*A*C*G*A*T*C-G*G*C*G*C*G*C*G*C*C*G-iT; (SEQ ID NO: 338)T*C-G*T*G-C*A*C-G*A*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 339)T*Z-G*T*C-G*A*C-G*A*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 340)T*C-G*T*Z-G*A*C-G*A*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 341)T*C-G*T*C-G*A*Z-G*A*T*C-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO 342)T*C-G*T*C-G*A*C-G*A*T*Z-G*G*C*G*C-G*C*G*C*C*G; (SEQ ID NO: 343)T*C-G*A*C*G*T*C-G*A*C*G*T*C-G*A*C*G; (SEQ ID NO: 343)T-C-G-A-C-G-T-C-G-A-C-G-T-C-G-A-C-G; (SEQ ID NO: 343)T*C*G*A*C*G*T*C*G*A*C*G*T*C*G*A*C*G; (SEQ ID NO: 344)T*C-G*T*C*G*A*C*G*T*T*C*G*G*C*G*C*C*G*T*G*C*C*G-iT; (SEQ ID NO: 344)T*C*G*T*C-G*A*C*G*T*T*C*G*G*C*G*C*C*G*T*G*C*C*G-iT; (SEQ ID NO: 344)T*C*G*T*C*G*A*C*G*T*T-C-G*G*C*G*C*C*G*T*G*C*C*G-iT; (SEQ ID NO: 345)G*C*C*G*C*G-C*G*C*G*G-C*iT*1A*1G-iC*IA*IG-iC*IT*IG-iC*IT;(SEQ ID NO: 346)C*G*G*C*G*C-G*C*G*C*C-G*iT*1A*1G-iC*IA*IG-iC*IT*IG-iC*IT;(SEQ ID NO: 345)G*C*C*G*C*G*C*G*C*G*G*C*iT*1A*iG*IC*IA*IG-iC*IT*IG*IC*IT;(SEQ ID NO: 346)C*G*G*C*G*C*G*C*G*C*C*G*iT*1A*iG*IC*IA*IG-iC*IT*IG*IC*IT;(SEQ ID NO: 347)C*G*G*C*G*C*C-G*T*G*C*C*G*iT*iT*iG*IC*IA*IG-iC*IT*IG*IC*IT;(SEQ ID NO: 348)G*C*C*G*T*G-C*C*G*C*G*G-C*iT*iT*iG*IC*IA*IG-iC*IT*IG*IC*IT;(SEQ ID NO: 347)C*G*G*C*G*C*C*G*T*G*C*C*G*iT*iT*iG*IC*IA*IG-iC*IT*IG*IC*IT;(SEQ ID NO: 348)G*C*C*G*T*G*C*C*G*C*G*G*C*iT*iT*iG*IC*IA*IG-iC*IT*IG*IC*IT;(SEQ ID NO: 349)T*C*G*G*C*G*C-G*C*G*C*C-G*A*iT*IA*IG-iC*IA*IG-iC*IT*IG-iC*IT;(SEQ ID NO: 349)T*C*G*G*C*G*C*G*C*G*C*C*G*A*iT*IA*IG*IC*IA*IG-iC*IT*IG*IC*IT;(SEQ ID NO: 350)T*C*G*G*C*G*C*C-G*T*G*C*C*G*iT*IT*IG*IC*IA*IG-iC*IT*IG*IC*IT;(SEQ ID NO: 350)T*C*G*G*C*G*C*C*G*T*G*C*C*G*iT*IT*IG*IC*IA*IG-iC*IT*IG*IC*IT;(SEQ ID NO: 351) C-G-G-C-G-C-X-G-C-G-C-C-G; (SEQ ID NO: 287)T-C_G*T*C_G*A*C_G*T*T*C_G*G*C*G*C_G*C*G*C*C*G; (SEQ ID NO: 352)T*C*G*T*C*G*A*C*G*A*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 353)T*C*G*T*C*G*A*C*G*A*J*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 354)T*C*G*T*C*G*A*C*G*A*L*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 355)T*C*G*T*C*G*A*C*G*A*D*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 79)G*G*G-G-A-C-G-A-C-G-T-C-G-T-G-G*G*G*G*G*G; (SEQ ID NO: 356)T*C-G-A-C-G-T-C-G-T-G-G*G*G*G; (SEQ ID NO: 357)T*C*C*A*G*G*A*C*T*T*C*T*C*T*C*A; (SEQ ID NO: 83)T*C*G*T*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 358)T*C*G*T*C-mG*mA*C*mG*mA*T*C*mG*mG*C*mG*C*mG*C*mG*C*C*mG;(SEQ ID NO: 359)T*C*mG*T*C*mG*mA*C*mG*mA*T*C*mG*mG*C*mG*C*mG*C*mG*C*C*mG;(SEQ ID NO: 358)T*C*G*T*C-mG*mA*C-mG*mA*T*C-mG*mG*C*mG*C-mG*C*mG*C*C*mG;  and(SEQ ID NO: 359)T*C-mG*T*C-mG*mA*C-mG*mA*T*C-mG*mG*C*mG*C-mG*C*mG*C*C*mG,wherein: — represents phosphodiester linkage; * represents stabilizedinternucleotide linkage; biot represents Biotin; but representsbutyrate; chol represents Cholesterol; Cy3 representsBis-hydroxypropyl-3,3,3′,3′-tetramethyl-4,5-benzindocarbocyaninechloride (Glen Research); D represents D spacer (1′2′-dideoxyribose,Glen Research, Sterling, Va.); dig represents Digoxygenin;doub-represents doubler; iN represents Inverse nucleotide (inverseorientation: 3′ and 5′ switched); J represents 1,3-propane-diol; Lrepresents hexaethylene glycol; mN represents 2′-O-methyl nucleoside; rNrepresents ribonucleoside; teg represents Triethylene glycol; vitErepresents Vitamin E; and Z represents 5-methyl-deoxycytidine.

Another recently-discovered class of CpG ODN is the E-class, in whichhalogen-modified nucleotides are placed immediately 5′ to the CpG motifas described in U.S. Pat. No. 8,580,268 and U.S. Published Application2014/0163213, the entire contents of both of which are incorporatedherein by reference. These ODN also induce much higher levels of type IIFN relative to the modest IL-10 production.

Examples of E-class ODN include:

(SEQ ID NO: 360) T*G*FF*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 361) T*G*T*C-G*FF*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 362) T*G*FF*C-G*FF*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 363) T*G*T*FF-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 364) T*G*T*C-FF*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 365) T*FF*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 366) T*G*T*C-G*T*FF*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 367) T*G*BU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO:368) T*G*T*C-G*BU*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 369) T*G*BU*C-G*BU*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 370) T*G*JU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 371) T*G*T*C-G*JU*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 372) T*G*JU*C-G*JU*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 373) T*G*U*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 374) T*G*T*C-G*U*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 375) T*G*U*C-G*U*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 376)JU*C*G*T*C*G*T*T*T*T*T*C*G*G*T*C*G*T*T*T*T; (SEQ ID NO: 377)T*C*G*JU*C*G*T*T*T*T*T*C*G*G*T*C*G*T*T*T*T; (SEQ ID NO: 378)T*C*G*T*C*G*T*T*T*T*T*C*G*G*JU*C*G*T*T*T*T; (SEQ ID NO: 379)JU*C*G*JU*C*G*T*T*T*T*T*C*G*G*T*C*G*T*T*T*T; (SEQ ID NO: 380)T*C*G*JU*C*G*JU*T*T*T*T*C*G*G*T*C*G*T*T*T*T; (SEQ ID NO: 381)T*C*G*T*C*G*T*T*T*T*T*C*G*G*JU*C*G*JU*T*T*T; (SEQ ID NO: 382)JU*C-G*T*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C*C*G; (SEQ ID NO: 383)T*C*G*JU*C-G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C*C*G; (SEQ ID NO: 384)T*G*T*C-G*EU*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 385)T*G*EU*C-G*EU*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 386)JU*C-G*T*C*G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 387)T*C*G*JU*C-G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 388)JU*C-G*JU*C*G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 389)JU*C-G-A-C-G-T-C-G-T-G-G*G*G*G; (SEQ ID NO: 390)T*C-G-A-C-G-JU-C-G-T-G-G*G*G*G; (SEQ ID NO: 391)T*C-G-A-C-G-JU-C-G-JU-G-G*G*G*G; G*JU*C-G*T*T; G*JU*C-G*JU*T;(SEQ ID NO: 392) T*G*CU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 393) T*G*EU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 394) JU*C-G*JU*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C*C*G;(SEQ ID NO: 395) T*C-G*JU*C*G*JU*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C*C*G;(SEQ ID NO: 396) T*C*T*T*T*T*T*T*G*JU*C-G*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 397) T*C*T*T*T*T*T*T*G*JU*C-G*JU*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 398) JU*C*T*T*T*T*T*T*G*T*C-G*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 398) JU*C-T*T*T*T*T*T*G*T*C-G*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 399) T*C*T*T*T*T*T*T*G*U*C-G*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 400) JU*C-G*A*C*G*T*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G;(SEQ ID NO: 400) JU*C*G*A*C*G*T*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G;(SEQ ID NO: 401) JU*C-G*A*C*G*T*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G*T;(SEQ ID NO: 401) JU*C*G*A*C*G*T*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G*T;(SEQ ID NO: 402) EU*C-G*A*C*G*T*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G;(SEQ ID NO: 402) EU*C*G*A*C*G*T*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G;(SEQ ID NO : 403) JU*C-G*T*C*G*A*C*G*A*T*C*G*G*C*G*G*C*C*G*C*C*G*T;(SEQ ID NO : 403) JU*C*G*T*C*G*A*C*G*A*T*C*G*G*C*G*G*C*C*G*C*C*G*T;(SEQ ID NO: 404) EU*C-G*T*C*G*A*C*G*A*T*C*G*G*C*G*G*C*C*G*C*C*G; (SEQ ID NO: 405) JU*C-G*T*C*G*A*C*G*A*T*C*G*G*C*G*G*C*C*G*C*C*G;(SEQ ID NO: 406) T*G*T*C-G*FU*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 407) T*G*FU*C-G*FU*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 408) T*G*U*C-G*UT*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 409) T*G*T*C-6NB*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 410) T*G*T*6NB-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 410) T*G*T*6NB-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 411) JU*G*T*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 412) JU*G*JU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 413) T*G*T*C-G*T*JU*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 414) T*G*FT*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 415) T*G*T*C-G*FT*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 416) T*G*FT*C-G*FT*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 392) T*G*CU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 417) T*G*T*C-G*CU*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 418) T*G*CU*C-G*CU*T*T*T*T*T*T*T*T*T*T*T*T*T*T;(SEQ ID NO: 419) T*JU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;T*G*JU*C-G*T*T*T*T; (SEQ ID NO: 420) T*G*JU*C-G*T*T*T*T*G*T*C-G*T*T;(T*G*JU*C-G*T*T*L*)2doub-3mG; (JU*C*G*T*T*C*G*L*)2doub-3mG;(SEQ ID NO: 421) T*T*JU*C-G*T*C-G*T*T*T*C-G*T*C-G*T*T; (SEQ ID NO: 422)BU*C-G-A-C-G-T-C-G-T-G-G-G*G*G; (SEQ ID NO: 423)T*G*JU*G-C*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (T*G*JU*C-G*T*T*L*)2doub-teg;(JU*C*G*T*T*C*G*L*)2doub-teg; (SEQ ID NO: 424)JU*C-G*T*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 425)T*C*G*JU*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 426)T*C*G*T*C*G*T*T*T*JU*C-G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 427)JU*C*G*T*C*G*T*T*T*T*T*C*G*G*JU*C*G*T*T*T*T; (SEQ ID NO: 428)T*C*G*JU*C*G*T*T*T*T*T*C*G*G*JU*C*G*T*T*T*T; (SEQ ID NO: 429)T*G*JU*C-G*T*T*T*T*T*T*T*T*T*G*JU*C-G*T*T; (SEQ ID NO: 430)T*G*JU*C*G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 431)JU*C-G-A-C-G-T-C-G-T-G-G*E*G*G; (SEQ ID NO: 432)T*mG*JU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 433)T*G*JU*C-mG*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 434)T*mG*JU*C-mG*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 379)JU*C-G*JU*C*G*T*T*T*T*T*C*G*G*T*C*G*T*T*T*T; (SEQ ID NO: 379)JU*C*G*JU*C-G*T*T*T*T*T*C*G*G*T*C*G*T*T*T*T; (SEQ ID NO: 435)T*G*PU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 436)T*G*T*C-G*PU*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 422)BU*C-G-A-C-G-T-C-G-T-G-G-*G*G*G; (SEQ ID NO: 437)T*G*JU*C-G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 438)T*JU*C-G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 439)T*EU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 440)T*G*EU*G-C*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 376)JU*C-G*T*C*G*T*T*T*T*T*C*G*G*T*C*G*T*T*T*T; (SEQ ID NO: 441)EU*C-G*T*C*G*T*T*T*T*T*C*G*G*T*C*G*T*T*T*T; G*JU*C-G*T*T-hex;G*JU*C-G*JU*T-hex; G*EU*C-G*EU*T-hex; (SEQ ID NO: 442)EU*C-G*T*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C*C*G; (SEQ ID NO: 443)T*C*G*EU*C-G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C*C*G; (SEQ ID NO: 444)EU*C-G*T*C*G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 445)JU*C*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 446)JU*C*T*T*T*T*T*T*T*T*C*G*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 447)T*C*T*T*T*T*T*T*T*JU*C*G*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 448)JU*C*T*T*T*T*T*T*T*JU*C*G*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 449)JU*C-G*T*C*G*T*T*T*C*G*T*C*G*T*T*T*T*G*T*C*G*T*T; (SEQ ID NO: 450)T*C*G*T*C*G*T*T*T*C*G*T*C*G*T*T*T*T*G*JU*C-G*T*T; (SEQ ID NO: 451)JU*C-G*T*C*G*T*T*T*C*G*T*C*G*T*T*T*T*G*JU*C-G*T*T; (SEQ ID NO: 452)T*G*JU*C-E*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 453)T*G*JU*C-I*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 454)T*G*JU*Z-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 455)T*G*T*C-G*T*T*JU*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 456)T*G*T*C-G*T*T*T*JU*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 457)JU*C-G*T*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 458)EU*C-G*T*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 459)T*C-G*EU*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 460)T*C-G*T*C*G*T*T*T*JU*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 461)T*C-G*T*C*G*T*T*T*EU*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 462)EU*C-G*T*C*G*T*T*T*EU*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 463)EU*C-G*EU*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 464)JU*C-G*EU*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 465)JU*C-G*T*C*G*T*T*T*T*G*T*C*G*T*T*T*T*G*T*C*G*T*T; (SEQ ID NO: 466)EU*C-G*T*C*G*T*T*T*T*G*T*C*G*T*T*T*T*C*G*T*T; (SEQ ID NO: 467)T*G*BVU*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 468)T*G*T*C-G*BVU*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 469)JU*C*G*G*C*G*G*C*C*G*C*C*G; (SEQ ID NO: 470)JU*C*G*T*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C* C*3mG; (SEQ ID NO: 471)EU*C*G*T*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C* C*3mG; (SEQ ID NO: 472)EU*C*G*EU*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C* C*3mG; (SEQ ID NO: 472)EU*C-G*EU*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C* C*3mG; (SEQ ID NO: 473)EU*C*G*T*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C* C*G*iT; (SEQ ID NO: 474)JU*C*G*T*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*3mG; (SEQ ID NO: 475)EU*C*G*T*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*3mG; (SEQ ID NO: 475)EU*C-G*T*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*3mG; (SEQ ID NO: 476)EU*C*G*EU*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*3mG; (SEQ ID NO: 476)EU*C-G*EU*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*3mG; (SEQ ID NO: 477)EU*C*G*T*C*G*T*T*T*EU*C*G*G*C*G*C*G*C*G*C*C*3mG; (SEQ ID NO: 478)JU*C*G*T*C*G*T*T*T*JU*C*G*G*C*G*C*G*C*G*C*C*3mG; (SEQ ID NO: 479)EU*C*G*T*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*iT; (SEQ ID NO: 480)JU*C*G*T*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*iT; (SEQ ID NO: 481)EU*C*G*T*C*G*A*C*G*T*T*C*G*G*C*G*C*C*G*T*G*C* C*3mG; (SEQ ID NO: 482)JU*C*G*T*C*G*A*C*G*T*T*C*G*G*C*G*C*C*G*T*G*C* C*3mG; (SEQ ID NO: 483)JU*C*G*T*C*G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*3mG; (SEQ ID NO: 484)EU*C*G*T*C*G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*3mG; (SEQ ID NO: 485)EU*C*G*T*C*G*A*C*G*T*T*C*G*G*C*G*C*C*G*T*G*C* C*G*iT; (SEQ ID NO: 486)EU*C*G*T*C*G*A*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G*iT; (SEQ ID NO: 487)T*G*NI*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 488)T*G*NP*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 489)T*G*6NB*C-G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T; (SEQ ID NO: 441)EU*C*G*T*C*G*T*T*T*T*T*C*G*G*T*C*G*T*T*T*T; (SEQ ID NO: 490)JU*C*G*T*C*G*A*C*G*A*T*G*G*C*G*G*C*G*C*C*G*C*C; (SEQ ID NO: 491)EU*C*G*T*C*G*A*C*G*A*T*G*G*C*G*G*C*G*C*C*G*C*C; (SEQ ID NO: 492)T*T*C-G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 493)T*EU*C-G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 494)JU*C-G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 495)JU*JU*C-G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 438)T*JU*C*G*T*T*T*T*C*G*G*C*G*C*G*C*G*C*C*G*T; (SEQ ID NO: 496)EU*C*G*T*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C*C* G*T; (SEQ ID NO: 497)T*EU*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C*C*G*T; (SEQ ID NO: 498)T*JU*C*G*T*T*T*T*A*C*G*G*C*G*C*C*G*T*G*C*C*G*T; (SEQ ID NO: 499)JU*C*G*T*C*G*T*T*T*T*rG*rU*rU*rG*rU*rG*rU; (SEQ ID NO: 500)EU*C-G*T*C*G*A*C*G*A*T*C*G*G*C*G*G*C*C*G*C*C*G*T; (SEQ ID NO: 500)EU*C*G*T*C*G*A*C*G*A*T*C*G*G*C*G*G*C*C*G*C*C*G*T; (SEQ ID NO: 402)EU-C-G*A*C*G*T*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G; (SEQ ID NO: 402)EU-C*G*A*C*G*T*C*G*A*T*C*G*G*C*G*C*G*C*G*C*C*G;(SEQ ID NO:) (SEQ ID NO: 373)T*G*U*C*G*T*T*T*T*T*T*T*T*T*T*T*T*T*T*T;and (SEQ ID NO: 374)T*G*T*C-G*U*T*T*T*T*T*T*T*T*T*T*T*T*T*T,wherein: — represents phosphodiester internucleotide linkage; *represents phosphorothioate internucleotide linkage; 2doub representsDoubler2 (Chemgenes); 3mG represents 3′-O-Methyl-rG; 6NB represents6-nitro-benzimidazol; BU represents 5-bromo-2′-deoxyuridine; BVUrepresents 5-(d-bromo-vinyl)-uridine; CU represents5-chloro-2′-deoxyuridine; E represents 7-deaza-dG; EU represents5-ethyl-2′-deoxyuridine; F represents 5-fluoro-dU; FF represents2,4-difluorotoluene; FT represents a,a,a-trifluoro-dT; FU represents5-fluoro-dU; hex represents hexadecylglyceryl; I represents inosine; iTrepresents inverse nucleotide (3′ and 5′ switched); JU represents5-iodo-2′-deoxyuridine; L represents Spacer 18 (hexaethylenglycolphosphate); NI represents nitroindol; NP represents nitropyrrol; PUrepresents 5-proynyl-dU; teg represents Spacer 9 (triethylenglycolphosphate); U represents Uridine; and Z represents 5-methyl-dC.

Methods to reduce the amount of B cell activation with CpG ODN andincrease or maintain the amount of IFN-α induction are not well known tothose skilled in the art, but without committing to a particularmechanism of action underlying the invention, it has now been discoveredin accordance with the invention that B cell proliferation and IL-10secretion appear to require a more sustained TLR9 signal compared tothat required to induce plasmacytoid dendritic cells (pDC) to secreteIFN-α. Such a sustained TLR9 signal is provided by the B-class CpG ODNto a greater degree than the other CpG ODN classes mentioned above. Inaddition, the duration of the TLR9 signal can be shortened bypositioning phosphodiester (PO) linkages at the CpG (“semi-soft”designs) and or at other positions within the ODN. The “softest” CpG ODNwith the least sustained B cell activation are those with completelyphosphodiester backbones, but these are so rapidly degraded in vivo thatthe IFN-α response is also compromised, unless the ODN is circular (toprotect against exonucleases), or is delivered in a formulation such asvirus-like particles (VLP), nanoparticles (NP), immune stimulatingcomplexes (ISCOMs), or the like, which also protects against nucleases.

The immunostimulatory oligonucleotide molecules may have a homogeneousbackbone (e.g., entirely phosphodiester (PO) or entirelyphosphorothioate (PS)) or a chimeric backbone. An exception to this isthe A-class CpG design (and A/E-class) in which the central portion ofthe ODN including at least 8 nucleotides and preferably 10 or morenucleotides must be phosphodiester for optimal activity. For purposes ofthe instant invention, a chimeric backbone refers to a partiallystabilized backbone, wherein at least one internucleotide linkage isphosphodiester or phosphodiester-like, and wherein at least one otherinternucleotide linkage is a stabilized internucleotide linkage, whereinthe at least one phosphodiester or phosphodiester-like linkage and theat least one stabilized linkage are different. The stabilized linkage(s)is/are preferentially placed at the 5′ and 3′ ends of theoligonucleotide in order to protect the ends from exonucleases: thephosphodiester linkages are placed in the middle and contribute toinducing a stronger IFN-α response than can easily be achieved with PSalone.

Since boranophosphonate linkages have been reported to be stabilizedrelative to phosphodiester linkages, for purposes of the chimeric natureof the backbone, boranophosphonate linkages can be classified either asphosphodiester-like or as stabilized, depending on the context. Forexample, a chimeric backbone according to the instant invention could,in one embodiment, include at least one phosphodiester (phosphodiesteror phosphodiester-like) linkage and at least one boranophosphonate(stabilized) linkage. In another embodiment, a chimeric backboneaccording to the instant invention could include boranophosphonate(phosphodiester or phosphodiester-like) and phosphorothioate(stabilized) linkages. A “stabilized internucleotide linkage” shall meanan internucleotide linkage that is relatively resistant to in vivodegradation (e.g., via an exo- or endo-nuclease), compared to aphosphodiester internucleotide linkage. Preferred stabilizedinternucleotide linkages include, without limitation, phosphorothioate,phosphorodithioate, methylphosphonate and methylphosphorothioate. Otherstabilized internucleotide linkages include, without limitation,peptide, alkyl, dephospho type linkages, and others as described above.

Modified backbones such as phosphorothioates may be synthesized usingautomated techniques employing either phosphoramidate or H-phosphonatechemistries. Aryl- and alkyl-phosphonates can be made, e.g., asdescribed in U.S. Pat. No. 4,469,863; and alkylphosphotriesters (inwhich the charged oxygen moiety is alkylated), e.g., as described inU.S. Pat. No. 5,023,243 and European Patent No. 092,574, can be preparedby automated solid phase synthesis using commercially availablereagents. Methods for making other DNA backbone modifications andsubstitutions have been described. Uhlmann E et al. (1990) Chem Rev90:544; Goodchild J (1990) Bioconjugate Chem 1:165. Methods forpreparing chimeric oligonucleotides are also known. For instance patentsissued to Uhlmann et al. have described such techniques, including, forexample, U.S. Pat. Nos. 7,566,703, 7,795,235, 8,283,328, and 8,304,396.

Mixed backbone modified ODN may be synthesized using a commerciallyavailable DNA synthesizer and standard phosphoramidite chemistry. F. E.Eckstein, “Oligonucleotides and Analogues—A Practical Approach”, IRLPress, Oxford, U K, 1991; and M. D. Matteucci and M. H. Caruthers,Tetrahedron Lett. 21, 719 (1980). After coupling, phosphorothioate (PS)linkages are introduced by sulfurization using the Beaucage reagent (R.P. Iyer, W. Egan, J. B. Regan and S. L. Beaucage, J. Am. Chem. Soc. 112,1253 (1990)) (0.075 M in acetonitrile) or phenyl acetyl disulfide (PADS)followed by capping with acetic anhydride, 2,6-lutidine intetrahydrofurane (1:1:8; v:v:v) and N-methylimidazole (16% intetrahydrofurane). This capping step is performed after thesulfurization reaction to minimize formation of undesired phosphodiester(PO) linkages at positions where a phosphorothioate linkage should belocated. In the case of the introduction of a phosphodiester linkage,e.g. at a CpG dinucleotide, the intermediate phosphorous-III is oxidizedby treatment with a solution of iodine in water/pyridine. After cleavagefrom the solid support and final deprotection by treatment withconcentrated ammonia (15 hrs at 50° C.), the ODN are analyzed by HPLC ona Gen-Pak Fax column (Millipore-Waters) using a NaCl-gradient (e.g.buffer A: 10 mM NaH₂PO4 in acetonitrile/water=1:4/v:v pH 6.8; buffer B:10 mM NaH₂PO₄, 1.5 M NaCl in acetonitrile/water=1:4/v:v; 5 to 60% B in30 minutes at 1 ml/min) or by capillary gel electrophoresis. The ODN canbe purified by HPLC or by FPLC on a Source High Performance column(Amersham Pharmacia). HPLC-homogeneous fractions are combined anddesalted via a C18 column or by ultrafiltration. The ODN was analyzed byMALDI-TOF mass spectrometry to confirm the calculated mass.

The oligonucleotides of the invention can also include othermodifications. These include nonionic DNA analogs, such as alkyl- andaryl-phosphates (in which the charged phosphonate oxygen is replaced byan alkyl or aryl group), phosphodiester and alkylphosphotriesters, inwhich the charged oxygen moiety is alkylated. Oligonucleotides whichcontain diol, such as tetraethyleneglycol or hexaethyleneglycol, ateither or both termini have also been shown to be substantiallyresistant to nuclease degradation.

In some embodiments the oligonucleotides may be “soft” or “semi-soft”oligonucleotides. A soft oligonucleotide is an immunostimulatoryoligonucleotide having a partially stabilized backbone, in whichphosphodiester or phosphodiester-like internucleotide linkages occuronly within and immediately adjacent to at least one internalpyrimidine-purine dinucleotide (YZ). Preferably YZ is YG, apyrimidine-guanosine (YG) dinucleotide. The at least one internal YZdinucleotide itself has a phosphodiester or phosphodiester-likeinternucleotide linkage. A phosphodiester or phosphodiester-likeinternucleotide linkage occurring immediately adjacent to the at leastone internal YZ dinucleotide can be 5′, 3′, or both 5′ and 3′ to the atleast one internal YZ dinucleotide.

In particular, phosphodiester or phosphodiester-like internucleotidelinkages involve “internal dinucleotides”. An internal dinucleotide ingeneral shall mean any pair of adjacent nucleotides connected by aninternucleotide linkage, in which neither nucleotide in the pair ofnucleotides is a terminal nucleotide, i.e., neither nucleotide in thepair of nucleotides is a nucleotide defining the 5′ or 3′ end of theoligonucleotide. Thus a linear oligonucleotide that is n nucleotideslong has a total of n−1 dinucleotides and only n−3 internaldinucleotides. Each internucleotide linkage in an internal dinucleotideis an internal internucleotide linkage. Thus a linear oligonucleotidethat is n nucleotides long has a total of n−1 internucleotide linkagesand only n−3 internal internucleotide linkages. The strategically placedphosphodiester or phosphodiester-like internucleotide linkages,therefore, refer to phosphodiester or phosphodiester-likeinternucleotide linkages positioned between any pair of nucleotides inthe oligonucleotide sequence. In some embodiments the phosphodiester orphosphodiester-like internucleotide linkages are not positioned betweeneither pair of nucleotides closest to the 5′ or 3′ end.

Preferably a phosphodiester or phosphodiester-like internucleotidelinkage occurring immediately adjacent to the at least one internal YZdinucleotide is itself an internal internucleotide linkage. Thus for asequence N₁ YZ N₂, wherein N₁ and N₂ are each, independent of the other,any single nucleotide, the YZ dinucleotide has a phosphodiester orphosphodiester-like internucleotide linkage, and in addition (a) N₁ andY are linked by a phosphodiester or phosphodiester-like internucleotidelinkage when N₁ is an internal nucleotide, (b) Z and N₂ are linked by aphosphodiester or phosphodiester-like internucleotide linkage when N₂ isan internal nucleotide, or (c) N₁ and Y are linked by a phosphodiesteror phosphodiester-like internucleotide linkage when N₁ is an internalnucleotide and Z and N₂ are linked by a phosphodiester orphosphodiester-like internucleotide linkage when N₂ is an internalnucleotide.

Soft oligonucleotides according to the instant invention are believed tobe relatively susceptible to nuclease cleavage compared to completelystabilized oligonucleotides. Without intending to be bound to aparticular theory or mechanism, it is believed that softoligonucleotides of the invention are susceptible to cleavable resultingin fragments with reduced or no immunostimulatory activity relative tofull-length soft oligonucleotides. Incorporation of at least onenuclease-sensitive internucleotide linkage, particularly near the middleof the oligonucleotide, is believed to provide an “off switch” whichalters the pharmacokinetics and pharmacodynamics of the oligonucleotideso as to reduce the duration of maximal immunostimulatory activity ofthe oligonucleotide. In particular, the nuclease-sensitive linkage mayreduce the magnitude of NF-κB induction while increasing the magnitudeof the IRF3 and/or IRF7 induction. TLR9 activation can lead to strongactivation of either or both of the NF-κB pathway (leading to expressionof cytokines such as IL-6 and expression of costimulatory molecules) andthe IRF3/7 pathways leading to IFN-α secretion. There generally seems tobe some antagonism between these pathways. For example, B-class CpG ODNpredominantly activate the former, whereas the A-class CpG ODN activatethe latter. Strong NF-κB induction is associated with B-class CpG oligosand may lead to increased IL-10 secretion. While this may be useful forsystemic CpG oligo therapy, it is not desirable for intratumoraltherapy. The increased IRF3/7 induction provided by thenuclease-sensitive internucleotide linkage leads to great production ofIFN-α in the tumor microenvironment, which improves the chances for aproductive and therapeutic anti-tumor immune response followingintratumoral therapy without increasing the production of undesirableIL-10. This reduced half-life of CpG oligos containingnuclease-sensitive linkages can be of particular value in tissues and inclinical applications in which it is desirable to avoid injury relatedto chronic local inflammation or immunostimulation, e.g., the kidney,since the oligos are less likely to accumulate in the tissue to highconcentrations.

A semi-soft oligonucleotide is an immunostimulatory oligonucleotidehaving a partially stabilized backbone, in which phosphodiester orphosphodiester-like internucleotide linkages occur only within at leastone internal pyrimidine-purine (YZ) dinucleotide. Semi-softoligonucleotides generally possess increased immunostimulatory potencyrelative to corresponding fully stabilized immunostimulatoryoligonucleotides. Due to the greater potency of semi-softoligonucleotides, semi-soft oligonucleotides may be used, in someinstances, at lower effective concentrations and have lower effectivedoses than conventional fully stabilized immunostimulatoryoligonucleotides in order to achieve a desired biological effect.

It is believed that the foregoing properties of semi-softoligonucleotides generally increase with increasing “dose” ofphosphodiester or phosphodiester-like internucleotide linkages involvinginternal YZ dinucleotides. Thus it is believed, for example, thatgenerally for a given oligonucleotide sequence with four internal YZdinucleotides, an oligonucleotide with four internal phosphodiester orphosphodiester-like YZ internucleotide linkages is moreimmunostimulatory than an oligonucleotide with three internalphosphodiester or phosphodiester-like YZ internucleotide linkages, whichin turn is more immunostimulatory than an oligonucleotide with twointernal phosphodiester or phosphodiester-like YZ internucleotidelinkages, which in turn is more immunostimulatory than anoligonucleotide with one internal phosphodiester or phosphodiester-likeYZ internucleotide linkage. Importantly, inclusion of even one internalphosphodiester or phosphodiester-like YZ internucleotide linkage oftencan be advantageous over no internal phosphodiester orphosphodiester-like YZ internucleotide linkage. In addition to thenumber of phosphodiester or phosphodiester-like internucleotidelinkages, the position along the length of the oligonucleotide can alsoaffect potency.

The soft and semi-soft oligonucleotides will generally include, inaddition to the phosphodiester or phosphodiester-like internucleotidelinkages at preferred internal positions, 5′ and 3′ ends that areresistant to degradation. Such degradation-resistant ends can involveany suitable modification that results in an increased resistanceagainst exonuclease digestion over corresponding unmodified ends. Forinstance, the 5′ and 3′ ends can be stabilized by the inclusion there ofat least one phosphate modification of the backbone. In a preferredembodiment, the at least one phosphate modification of the backbone ateach end is independently a phosphorothioate, phosphorodithioate,methylphosphonate, or methylphosphorothioate internucleotide linkage. Inanother embodiment, the degradation-resistant end includes one or morenucleotide units connected by peptide or amide linkages at the 3′ end.

A phosphodiester internucleotide linkage is the type of linkagecharacteristic of oligonucleotides found in nature. The phosphodiesterinternucleotide linkage includes a phosphorus atom flanked by twobridging oxygen atoms and bound also by two additional oxygen atoms, onecharged and the other uncharged. Phosphodiester internucleotide linkageis particularly preferred when it is important to reduce the tissuehalf-life of the oligonucleotide or to get the strongest possibleinduction of type I IFN secretion from pDC.

A phosphodiester-like internucleotide linkage is a phosphorus-containingbridging group that is chemically and/or diastereomerically similar tophosphodiester. Measures of similarity to phosphodiester includesusceptibility to nuclease digestion and ability to activate RNase H.Thus, for example phosphodiester, but not phosphorothioate,oligonucleotides are susceptible to nuclease digestion, while bothphosphodiester and phosphorothioate oligonucleotides activate RNAse H.In a preferred embodiment the phosphodiester-like internucleotidelinkage is boranophosphate (or equivalently, boranophosphonate) linkage.U.S. Pat. Nos. 5,177,198; 5,859,231; 6,160,109; 6,207,819; Sergueev atal., (1998) J Am Chem Soc 120:9417-27. In another preferred embodimentthe phosphodiester-like internucleotide linkage is diastereomericallypure Rp phosphorothioate. It is believed that diastereomerically pure Rpphosphorothioate is more susceptible to nuclease digestion and is betterat activating RNAse H than mixed or diastereomerically pure Spphosphorothioate. Stereoisomers of CpG oligonucleotides are the subjectof published PCT application PCT/US99/17100 (WO 00/06588). It is to benoted that for purposes of the instant invention, the term“phosphodiester-like internucleotide linkage” specifically excludesphosphorodithioate and methylphosphonate internucleotide linkages.

As described above the soft and semi-soft oligonucleotides of theinvention may have phosphodiester like linkages between C and G. Oneexample of a phosphodiester-like linkage is a phosphorothioate linkagein an Rp conformation. Oligonucleotide p-chirality can have apparentlyopposite effects on the immune activity of a CpG oligonucleotide,depending upon the time point at which activity is measured. Krieg etal., Oligonucleotides 2003 13(6):491-499. At an early time point of 40minutes, the Rp but not the Sp stereoisomer of phosphorothioate CpGoligonucleotide induces JNK phosphorylation in mouse spleen cells. Incontrast, when assayed at a late time point of 44 hr, the Sp but not theRp stereoisomer is active in stimulating spleen cell proliferation. Thisdifference in the kinetics and bioactivity of the Rp and Spstereoisomers does not result from any difference in cell uptake, butrather most likely is due to two opposing biologic roles of thep-chirality. First, the enhanced activity of the Rp stereoisomercompared to the Sp for stimulating immune cells at early time pointsindicates that the Rp may be more effective at interacting with the CpGreceptor, TLR9, or inducing the downstream signaling pathways. On theother hand, the faster degradation of the Rp PS-oligonucleotidescompared to the Sp results in a much shorter duration of signaling, sothat the Sp PS-oligonucleotides appear to be more biologically activewhen tested at later time points probably because of the greaternuclease-resistance of the Sp linkage, which provided a more sustainedsignal through TLR9 for B cell proliferation.

Thus the oligonucleotides may be heterogeneous in backbone compositionthereby containing any possible combination of polymer units linkedtogether.

The term “oligonucleotide” also encompasses oligonucleotides withsubstitutions or modifications, such as in the sugars. For example, theyinclude oligonucleotides having backbone sugars that are covalentlyattached to low molecular weight organic groups other than a hydroxylgroup at the 2′ position and other than a phosphate group or hydroxygroup at the 5′ position. Thus modified oligonucleotides may include a2′-O-alkylated ribose group. In addition, modified oligonucleotides mayinclude sugars such as arabinose or 2′-fluoroarabinose instead ofribose.

The immunostimulatory oligonucleotides of the instant invention canencompass various chemical modifications and substitutions, incomparison to natural RNA and DNA, involving a phosphodiesterinternucleotide bridge, or a 13-D-ribose unit. Examples of chemicalmodifications are known to the skilled person and are described, forexample, in Uhlmann E et al. (1990) Chem Rev 90:543; “Protocols forOligonucleotides and Analogs” Synthesis and Properties & Synthesis andAnalytical Techniques, S. Agrawal, Ed, Humana Press, Totowa, USA 1993;Crooke S T et al. (1996) Annu Rev Pharmacol Toxicol 36:107-129; andHunziker J et al. (1995) Mod Synth Methods 7:331-417. An oligonucleotideaccording to the invention may have one or more modifications, whereineach modification is located at a particular phosphodiesterinternucleotide bridge and/or at a particular β-D-ribose unit incomparison to an oligonucleotide of the same sequence which is composedof natural DNA or RNA.

For example, the invention relates to an oligonucleotide which maycomprise one or more modifications and wherein each modification isindependently selected from: a) the replacement of a phosphodiesterinternucleotide bridge located at the 3′ and/or the 5′ end of anucleotide by a modified internucleotide bridge; b) the replacement ofphosphodiester bridge located at the 3′ and/or the 5′ end of anucleotide by a dephospho bridge; c) the replacement of a sugarphosphate unit from the sugar phosphate backbone by another unit; and d)the replacement of a β-D-ribose unit by a modified sugar unit.

More detailed examples for the chemical modification of anoligonucleotide are as follows:

A phosphodiester internucleotide bridge located at the 3′ and/or the 5′end of a nucleotide can be replaced by a modified internucleotidebridge, wherein the modified internucleotide bridge is for exampleselected from phosphorothioate, phosphorodithioate,NR¹R²-phosphoramidate, boranophosphate, α-hydroxybenzyl phosphonate,phosphate-(C₁-C₂₁)—O-alkyl ester, phosphate-[(C₆-C₁₂)aryl—(C₁-C₂₁)—O-alkyl]ester, (C₁-C₈)alkylphosphonate and/or(C₆-C₁₂)arylphosphonate bridges, (C₇-C₁₂)-α-hydroxymethyl-aryl (e.g.,disclosed in WO 95/01363), wherein (C₆-C₁₂)aryl, (C₆-C₂₀)aryl and(C₆-C₁₄)aryl are optionally substituted by halogen, alkyl, alkoxy,nitro, cyano, and where R¹ and R² are, independently of each other,hydrogen, (C₁-C₁₈)-alkyl, (C₆-C₂₀)-aryl, (C₆-C₁₄)-aryl-(C₁-C₈)-alkyl,preferably hydrogen, (C₁-C₈)-alkyl, preferably (C₁-C₄)-alkyl and/ormethoxyethyl, or R¹ and R² form, together with the nitrogen atomcarrying them, a 5-6-membered heterocyclic ring which can additionallycontain a further heteroatom from the group O, S and N.

The replacement of a phosphodiester bridge located at the 3′ and/or the5′ end of a nucleotide by a dephospho bridge (dephospho bridges aredescribed, for example, in Uhlmann E and Peyman A in “Methods inMolecular Biology”, Vol. 20, “Protocols for Oligonucleotides andAnalogs”, S. Agrawal, Ed., Humana Press, Totowa 1993, Chapter 16, pp.355 ff), wherein a dephospho bridge is for example selected from thedephospho bridges formacetal, 3′-thioformacetal, methylhydroxylamine,oxime, methylenedimethyl-hydrazo, dimethylenesulfone and/or silylgroups.

A sugar phosphate unit (i.e., a β-D-ribose and phosphodiesterinternucleotide bridge together forming a sugar phosphate unit) from thesugar phosphate backbone (i.e., a sugar phosphate backbone is composedof sugar phosphate units) can be replaced by another unit, wherein theother unit is for example suitable to build up a “morpholino-derivative”oligomer (as described, for example, in Stirchak E P et al. (1989)Oligonucleotides Res 17:6129-41), that is, e.g., the replacement by amorpholino-derivative unit; or to build up a polyamide oligonucleotide(“PNA”; as described for example, in Nielsen P E et al. (1994) BioconjugChem 5:3-7), that is, e.g., the replacement by a PNA backbone unit,e.g., by 2-aminoethylglycine.

A 3-ribose unit or a β-D-2′-deoxyribose unit can be replaced by amodified sugar unit, wherein the modified sugar unit is for exampleselected from β-D-ribose, α-D-2′-deoxyribose, L-2′-deoxyribose,2′-F-2′-deoxyribose, 2′-F-arabinose, 2′-O—(C₁-C₆)alkyl-ribose,preferably 2′-O—(C₁-C₆)alkyl-ribose is 2′-O-methylribose,2′-O—(C₂-C₆)alkenyl-ribose, 2′-[O—(C₁-C₆)alkyl-O—(C₁-C₆)alkyl]-ribose,2′-NH₂-2′-deoxyribose, β-D-xylo-furanose, α-arabinofuranose,2,4-dideoxy-β-D-erythro-hexo-pyranose, and carbocyclic (described, forexample, in Froehler J (1992) J Am Chem Soc 114:8320) and/or open-chainsugar analogs (described, for example, in Vandendriessche et al. (1993)Tetrahedron 49:7223) and/or bicyclosugar analogs (described, forexample, in Tarkov M et al. (1993) Helv Chim Acta 76:481).

In some embodiments the sugar is 2′-O-methylribose, particularly for oneor both nucleotides linked by a phosphodiester or phosphodiester-likeinternucleotide linkage.

In particular sequences described herein a set of modified bases isdefined. For instance the letter Y is used to refer to a nucleotidecontaining a cytosine or a modified cytosine. A modified cytosine asused herein is a naturally occurring or non-naturally occurringpyrimidine base analog of cytosine which can replace this base withoutimpairing the immunostimulatory activity of the oligonucleotide.Modified cytosines include but are not limited to 5-substitutedcytosines (e.g., 5-methyl-cytosine, 5-fluoro-cytosine,5-chloro-cytosine, 5-bromo-cytosine, 5-iodo-cytosine,5-hydroxy-cytosine, 5-hydroxymethyl-cytosine, 5-difluoromethyl-cytosine,and unsubstituted or substituted 5-alkynyl-cytosine), 6-substitutedcytosines, N4-substituted cytosines (e.g., N4-ethyl-cytosine),5-aza-cytosine, 2-mercapto-cytosine, isocytosine, pseudo-isocyto sine,cytosine analogs with condensed ring systems (e.g., N,N′-propylenecytosine or phenoxazine), and uracil and its derivatives (e.g.,5-fluoro-uracil, 5-bromo-uracil, 5-bromovinyl-uracil, 4-thio-uracil,5-hydroxy-uracil, 5-propynyl-uracil). Some of the preferred cytosinesinclude 5-methyl-cytosine, 5-fluoro-cytosine, 5-hydroxy-cytosine,5-hydroxymethyl-cytosine, and N4-ethyl-cytosine. In another embodimentof the invention, the cytosine base is substituted by a universal base(e.g., 3-nitropyrrole, P-base), an aromatic ring system (e.g.,fluorobenzene or difluorobenzene) or a hydrogen atom (dSpacer).

The letter Z is used to refer to guanine or a modified guanine base. Amodified guanine as used herein is a naturally occurring ornon-naturally occurring purine base analog of guanine which can replacethis base without impairing the immunostimulatory activity of theoligonucleotide. Modified guanines include but are not limited to7-deazaguanine, 7-deaza-7-substituted guanine (such as7-deaza-7-(C2-C6)alkynylguanine), 7-deaza-8-substituted guanine,hypoxanthine, N2-substituted guanines (e.g., N2-methyl-guanine),5-amino-3-methyl-3H,6H-thiazolo[4,5-d]pyrimidine-2,7-dione,2,6-diaminopurine, 2-aminopurine, purine, indole, adenine, substitutedadenines (e.g., N6-methyl-adenine, 8-oxo-adenine) 8-substituted guanine(e.g., 8-hydroxyguanine and 8-bromoguanine), and 6-thioguanine. Inanother embodiment of the invention, the guanine base is substituted bya universal base (e.g., 4-methyl-indole, 5-nitro-indole, and K-base), anaromatic ring system (e.g. benzimidazole or dichloro-benzimidazole,1-methyl-1H-[1,2,4]triazole-3-carboxylic acid amide) or a hydrogen atom(dSpacer).

The oligonucleotides may have one or more accessible 5′ ends. It ispossible to create modified oligonucleotides having two such 5′ ends.This may be achieved, for instance by attaching two oligonucleotidesthrough a 3′-3′ linkage to generate an oligonucleotide having one or twoaccessible 5′ ends. The 3′3′-linkage may be a phosphodiester,phosphorothioate or any other modified internucleotide bridge. Methodsfor accomplishing such linkages are known in the art. For instance, suchlinkages have been described in Seliger, H. et al., Oligonucleotideanalogs with terminal 3′-3′- and 5′-5′-internucleotidic linkages asantisense inhibitors of viral gene expression, Nucleosides & Nucleotides(1991), 10(1-3), 469-77; and Jiang, et al., Pseudo-cyclicoligonucleotides: in vitro and in vivo properties, Bioorganic &Medicinal Chemistry (1999), 7(12), 2727-2735.

Additionally, 3′3′-linked oligonucleotides where the linkage between the3′-terminal nucleotides is not a phosphodiester, phosphorothioate orother modified bridge, can be prepared using an additional spacer, suchas tri- or tetra-ethyleneglycol phosphate moiety (Durand, M. et al,Triple-helix formation by an oligonucleotide containing one (dA)₁₂ andtwo (dT)₁₂ sequences bridged by two hexaethylene glycol chains,Biochemistry (1992), 31(38), 9197-204, U.S. Pat. Nos. 5,658,738, and5,668,265). Alternatively, the non-nucleotidic linker may be derivedfrom ethanediol, propanediol, or from an abasic deoxyribose (dSpacer)unit (Fontanel, Marie Laurence et al., Sterical recognition by T4polynucleotide kinase of non-nucleosidic moieties 5′-attached tooligonucleotides; Oligonucleotides Research (1994), 22(11), 2022-7)using standard phosphoramidite chemistry. The non-nucleotidic linkerscan be incorporated once or multiple times, or combined with each otherallowing for any desirable distance between the 3′-ends of the two ODNsto be linked.

The oligonucleotides may be partially resistant to degradation (e.g.,are stabilized). A “stabilized oligonucleotide molecule” shall mean anoligonucleotide that is relatively resistant to in vivo degradation(e.g. via an exo- or endo-nuclease). Oligonucleotide stabilization canbe accomplished via backbone modifications. Oligonucleotides havingphosphorothioate linkages provide maximal protection for theoligonucleotide from degradation by intracellular exo- andendo-nucleases. Other modified oligonucleotides include phosphodiestermodified oligonucleotides, combinations of phosphodiester andphosphorothioate oligonucleotide, methylphosphonate,methylphosphorothioate, phosphorodithioate, p-ethoxy, and combinationsthereof. Oligonucleotides which contain diol, such astetraethyleneglycol or hexaethyleneglycol, at either or both terminihave also been shown to be substantially resistant to nucleasedegradation. Circular ODN are protected against exonuclease degradation.For example, the Mologen double stem-loop immunomodulator MGN1703(formerly dSLIM-30L1) is a covalently closed 116-nucleotidedumbbell-shaped CpG-containing phosphodiester backbone oligonucleotidehaving the sequence5′-AGGTGGTAACCCCTAGGGGTTACCACCTTCATTGGAAAACGTTCTTCGGGGCGTTCTTAGGTGGTAACCCCTAGGGGTTACCACCTTCATTGGAAAACGTTCTTCG GGGCGTTCTT-3′(SEQ ID NO:501). Schmidt M et al., Allergy 2006 61: 56-63; Kapp, K etal., Mol Ther Nucleic Acids 2014 3: e170.

The immunostimulatory oligonucleotides may also contain one or moreunusual linkages between the nucleotide or nucleotide-analogousmoieties. The usual internucleoside linkage is a 3′5′-linkage. All otherlinkages are considered to be unusual internucleoside linkages, such as2′5′-, 5′5′-, 3′3′-, 2′2′-, 2′3′-linkages. The nomenclature 2′ to 5′ ischosen according to the carbon atom of ribose. However, if unnaturalsugar moieties are employed, such as ring-expanded sugar analogs (e.g.hexanose, cyclohexene or pyranose) or bi- or tricyclic sugar analogs,then this nomenclature changes according to the nomenclature of themonomer. In 3′-deoxy-β-D-ribopyranose analogs (also called p-DNA), themononucleotides are e.g. connected via a 4′2′-linkage.

If the oligonucleotide contains one 3′3′-linkage, then thisoligonucleotide may have two unlinked 5′-ends. Similarly, if theoligonucleotide contains one 5'S′-linkage, then this oligonucleotide mayhave two unlinked 3′-ends. The accessibility of unlinked ends ofnucleotides may be better accessible by their receptors. Both types ofunusual linkages (3′3′- and 5′5′) were described by Ramalho Ortigao etal. (Antisense Research and Development (1992) 2, 129-46), wherebyoligonucleotides having a 3′3′-linkage were reported to show enhancedstability towards cleavage by nucleases.

Different types of linkages can also be combined in one molecule whichmay lead to branching of the oligomer. If one part of theoligonucleotide is connected at the 3′-end via a 3′3′-linkage to asecond oligonucleotide part and at the 2′-end via a 2′3′-linkage to athird part of the molecule, this results e.g. in a branchedoligonucleotide with three 5′-ends (3′3′-, 2′3′-branched).

In certain embodiments of the invention, a sustained release deliverysystem, including for example nanoparticles, ISCOMS, VLP, and dendrimersmay be used to formulate and deliver a CpG-ODN. In one embodiment, a VLPas described in U.S. Pat. Nos. 9,518,095, 7,888,098, 9,404,126 (eachincorporated by reference in their entireties) is contemplated for usein the methods of the present disclosure. (See also, e.g., Manolova etal., Eur. J. Immunol., 2008, 38:1404-1413; Gomes et al., Vaccines, 2017,5,6; Gomes et al., Front. Immunol., 2017; 8:226; and Mohsen et al., J.Controlled Release, 251, 2017, 92-100).

III. Checkpoint Inhibitors A. PD-1

Programmed death-1 receptor (PD-1), also known as CD279, is a type 1membrane protein expressed on activated T cells (including CD8⁺ Tcells), B cells, and macrophages. Its cognate ligands are PD-L1 andPD-L2, and binding of PD-1 particularly by PD-L1 blocks “Signal 3” in Tcells and potently inhibits the effector arm of an adaptive immuneresponse, for example by leading to the death of T cells expressingPD-1.

In humans, PD-1 is a 268-amino acid polypeptide having an amino acidsequence published as GenBank Accession No. NP_005009. The proteinincludes an extracellular IgV domain, transmembrane domain, andintracellular domain having two phosphorylation sites.

The K_(D) for interaction between PD-1 and PD-L1 is 770 nM.

In preferred embodiments of the invention, the antibody inhibits bindingbetween PD-1 and PD-L1. Preferably, the antibody can inhibit bindingwith PD-L1 with an IC₅₀ of about 100 nM or lower; more preferably, about10 nM or lower, for example about 5 nM or lower; yet more preferably,about 2 nM or lower; or even more preferably, for example, about 1 nM orlower.

Further, in another embodiment, the anti-PD-1 antibody has a bindingaffinity for PD-1 that is at least as strong as that of PD-L1. Incertain embodiments, the anti-PD-1 antibody has a binding affinity forPD-1 that is at least 10 times as strong as that of PD-L1. In certainembodiments, the anti-PD-1 antibody has a binding affinity for PD-1 thatis at least 100 times as strong as that of PD-L1. In certainembodiments, the anti-PD-1 antibody has a binding affinity for PD-1 thatis at least 1000 times as strong as that of PD-L1.

Anti-PD-1 antibodies are known in the art and include, for example,those disclosed in U.S. Pat. No. 6,808,710 to Wood et al., U.S. Pat. No.7,488,802 to Collins et al., and U.S. Pat. No. 8,728,474 to Honjo et al.Anti-PD-1 antibodies are commercially available as pembrolizumab(formerly known as lambrolizumab and MK-3475, KEYTRUDA®, Merck, K_(D) 29pM) and nivolumab (OPDIVO®, Bristol-Myers Squibb, K_(D) 2.6 nM).Additional anti-PD-1 antibodies currently under development includepidilizumab (CT-011, Cure Tech).

B. PD-L1

Programmed death-ligand 1 receptor (PD-L1), also known as CD274 and B7homolog 1 (B7-H1), is a type 1 membrane protein expressed on activated Tcells (including CD8⁺ T cells and so-called tumor-infiltratinglymphocytes (TIL cells)), B cells, macrophages, and dendritic cells, aswell as on many types of tumor cells. Its cognate ligands are PD-1 andB7.1 (CD80), and binding of PD-1 by PD-L1 blocks “Signal 3” in T cellsand can potently inhibit the T cell effector functions mediating anadaptive immune response, for example by leading to the death of T cellsexpressing PD-1.

PD-L1 expression is upregulated on T cells, NK cells, macrophages,myeloid dendritic cells, B cells, epithelial cells, and vascularendothelial cells in response to interferon gamma (IFN-γ). PD-L1expression is also upregulated on tumors, e.g., renal cell carcinoma andovarian cancer, in response to IFN-γ.

In humans, PD-L1 is expressed in either of two isoforms, a longerisoform a or a shorter isoform b. Isoform a is a 290-amino acidpolypeptide having an amino acid sequence published as GenBank AccessionNo. NP_054862; the mature peptide comprises amino acid residues 19-290,with residues 239-259 representing the transmembrane domain. Isoform bis a 176-amino acid polypeptide having an amino acid sequence publishedas GenBank NP_001254635; the mature peptide comprises amino acidresidues 19-259.

As mentioned above, the K_(D) for interaction between PD-1 and PD-L1 is770 nM.

In preferred embodiments of the invention, the antibody inhibits bindingbetween PD-1 and PD-L1. Preferably, the antibody can inhibit bindingwith PD-1 with an IC₅₀ of about 100 nM or lower; more preferably, about10 nM or lower, for example about 5 nM or lower; yet more preferably,about 2 nM or lower; or even more preferably, for example, about 1 nM orlower.

Further, in another embodiment, the anti-PD-L1 antibody has a bindingaffinity for PD-L1 that is at least as strong as that of PD-1. Incertain embodiments, the anti-PD-L1 antibody has a binding affinity forPD-L1 that is at least 10 times as strong as that of PD-1. In certainembodiments, the anti-PD-L1 antibody has a binding affinity for PD-L1that is at least 100 times as strong as that of PD-1. In certainembodiments, the anti-PD-L1 antibody has a binding affinity for PD-L1that is at least 1000 times as strong as that of PD-1.

Anti-PD-L1 antibodies are known in the art and include, for example,those disclosed in U.S. Pat. No. 7,943,743 to Korman et al. While noanti-PD-L1 antibodies are yet approved by the FDA for commercializationin the United States, several anti-PD-L1 antibodies are currently underdevelopment in human clinical trials, including MPDL3280A(Genetech/Roche, K_(D) 0.4 nM), BMS-936559 (Bristol-Myers Squibb), andMEDI-4736 (AstraZeneca).

C. CTLA-4

Cytotoxic T-lymphocyte-associated protein 4 (CTLA-4), also known asCTLA4 or CD152, is a membrane protein expressed on T cells andregulatory T cells (Treg). Its cognate ligands include B7-1 (CD80) andB7-2 (CD86) on antigen-presenting cells (APC). Binding of B7-1 or B7-2by CTLA-4 blocks “Signal 2” in T cells and inhibits the initiation of anadaptive immune response.

In humans, CTLA-4 is encoded in various isoforms, including one with anamino acid sequence published as GenBank Accession No. NP_001032720.

A preferred anti-CTLA-4 antibody is an antibody that specifically bindsto human CTLA-4. More particularly, the anti-CTLA-4 antibodyspecifically binds to an epitope in the extracellular domain of humanCTLA-4 and inhibits binding between CTLA-4 and one or both of itscognate ligands B7-1 and B7-2.

A preferred anti-CTLA-4 antibody is a human antibody that specificallybinds to human CTLA-4. More particularly, the anti-CTLA-4 antibodyspecifically binds to an epitope in the extracellular domain of humanCTLA-4 and inhibits binding between CTLA-4 and one or both of itscognate ligands B7-1 and B7-2. Exemplary human anti-CTLA-4 antibodiesare described in detail in International Application No. PCT/US99/30895,published on Jun. 29, 2000 as WO 00/37504; European Patent Appl. No. EP1262193 A1, published Apr. 12, 2002; U.S. patent application Ser. No.09/472,087, now issued as U.S. Pat. No. 6,682,736, to Hanson et al.;U.S. patent application Ser. No. 09/948,939, published as US2002/0086014; U.S. patent application Ser. No. 11/988,396, published asUS 2009/0117132; and U.S. patent application Ser. No. 13/168,206,published as US 2012/0003179, the entire disclosures of which areincorporated herein by reference. Such antibodies include, but are notlimited to, 3.1.1, 4.1.1, 4.8.1, 4.10.2, 4.13.1, 4.14.3, 6.1.1, 11.2.1,11.6.1, 11.7.1, 12.3.1.1, and 12.9.1.1, as well as MDX-010. Humanantibodies provide a substantial advantage in the treatment methods ofthe present disclosure, as they are expected to minimize the immunogenicand allergic responses that are associated with use of non-humanantibodies in human patients.

Anti-CTLA-4 antibodies specifically include ipilimumab (YERVOY®,Bristol-Myers Squibb).

Characteristics of useful human anti-CTLA-4 antibodies of the inventionare extensively discussed in WO 00/37504, EP 1262193, and U.S. Pat. No.6,682,736 as well as U.S. Patent Application Publication Nos.US2002/0086014 and US2003/0086930, and the amino and nucleic acidsequences set forth therein are incorporated by reference herein intheir entirety. Briefly, the antibodies of the invention includeantibodies having amino acid sequences of an antibody such as, but notlimited to, antibody 3.1.1, 4.1.1, 4.8.1, 4.10.2, 4.13.1, 4.14.3, 6.1.1,11.2.1, 11.6.1, 11.7.1, 12.3.1.1, 12.9.1.1, and MDX-010. The inventionalso relates to antibodies having the amino acid sequences of the CDRsof the heavy and light chains of these antibodies, as well as thosehaving changes in the CDR regions, as described in the above-citedapplications and patent. The invention also concerns antibodies havingthe variable regions of the heavy and light chains of those antibodies.In another embodiment, the antibody is selected from an antibody havingthe full length, variable region, or CDR, amino acid sequences of theheavy and light chains of antibodies 3.1.1, 4.1.1, 4.8.1, 4.10.2,4.13.1, 4.14.3, 6.1.1, 11.2.1, 11.6.1, 11.7.1, 12.3.1.1, and 12.9.1.1,and MDX-010.

Methods of administering anti-CTLA-4 antibodies are well known in theart. Most commonly the antibodies are given by systemic administration,generally IV. In animal models but not humans, intra-tumoraladministration also has been explored as a way to reduce doses andtoxicity (Fransen M F et al., Oncoimmunology 2013 Nov. 1; 2(11):e26493).

In one embodiment, the invention comprises an antibody-therapeutic agentcombination comprising a human anti-CTLA-4 antibody disclosed in U.S.patent application Ser. No. 09/948,939, published as U.S. PatentApplication Publication No. 2002/0086014 and No. 2003/0086930, andreferences cited therein, including, but not limited to, MAb 10D1(MDX-010, Medarex, Princeton, N.J.). Even more preferably, theanti-CTLA-4 antibody is MDX-010. Alternatively, the anti-CTLA-4 antibodyis 11.2.1 (Ticilimumab; CP-675,206).

In preferred embodiments of the invention, the antibody inhibits bindingbetween CTLA-4 and B7-1, B7-2, or both. Preferably, the antibody caninhibit binding with B7-1 with an IC₅₀ of about 100 nM or lower; morepreferably, about 10 nM or lower, for example about 5 nM or lower; yetmore preferably, about 2 nM or lower; or even more preferably, forexample, about 1 nM or lower. Likewise, the antibody can inhibit bindingwith B7-2 with an IC₅₀ of about 100 nM or lower; more preferably, 10 nMor lower, for example, even more preferably, about 5 nM or lower; yetmore preferably, about 2 nM or lower; or even more preferably, about 1nM or lower.

Further, in another embodiment, the anti-CTLA-4 antibody has a bindingaffinity for CTLA-4 that is at least as strong as that of B7-1. Incertain embodiments, the anti-CTLA-4 antibody has a binding affinity forCTLA-4 that is at least 10 times as strong as that of B7-1. In certainembodiments, the anti-CTLA-4 antibody has a binding affinity for CTLA-4that is at least 100 times as strong as that of B7-1. In certainembodiments, the anti-CTLA-4 antibody has a binding affinity for CTLA-4that is at least 1000 times as strong as that of B7-1.

Further, in another embodiment, the anti-CTLA-4 antibody has a bindingaffinity for CTLA-4 that is at least as strong as that of B7-2. Incertain embodiments, the anti-CTLA-4 antibody has a binding affinity forCTLA-4 that is at least 10 times as strong as that of B7-2. In certainembodiments, the anti-CTLA-4 antibody has a binding affinity for CTLA-4that is at least 100 times as strong as that of B7-2. In certainembodiments, the anti-CTLA-4 antibody has a binding affinity for CTLA-4that is at least 1000 times as strong as that of B7-2.

Further, in another embodiment, the anti-CTLA-4 antibody has a bindingaffinity for CTLA-4 of about 10⁻⁸ M, or greater affinity, morepreferably, about 10⁻⁹ M or greater affinity, more preferably, about10⁻¹⁰ M or greater affinity, and even more preferably, about 10⁻¹¹ M orgreater affinity.

In certain embodiments, the anti-CTLA-4 antibody can compete for bindingwith an antibody having heavy and light chain amino acid sequences of anantibody selected from the group consisting of 4.1.1, 6.1.1, 11.2.1,4.13.1 and 4.14.3. Further, in certain embodiments, the anti-CTLA-4antibody can compete for binding with an MDX-010 antibody.

In another embodiment, the anti-CTLA-4 antibody preferablycross-competes with an antibody having a heavy and light chain sequence,a variable heavy and a variable light chain sequence, and/or the heavyand light CDR sequences of antibody 4.1.1, 4.13.1, 4.14.3, 6.1.1 or11.2.1. For example, the antibody can bind to the epitope to which anantibody that has heavy and light chain amino acid sequences, variablesequences and/or CDR sequences, of an antibody selected from the groupconsisting of 4.1.1, 4.13.1, 4.14.3, 6.1.1, or 11.2.1 binds. In anotherembodiment, the anti-CTLA-4 antibody cross-competes with an antibodyhaving heavy and light chain sequences, or antigen-binding sequences, ofMDX-010.

In another embodiment, the invention is practiced using an anti-CTLA-4antibody that comprises a heavy chain comprising the amino acidsequences of CDR1, CDR2, and CDR3, and a light chain comprising theamino acid sequences of CDR1, CDR2, and CDR3, of an antibody selectedfrom the group consisting of 3.1.1, 4.1.1, 4.8.1, 4.10.2, 4.13.1,4.14.3, 6.1.1, 11.2.1, 11.6.1, 11.7.1, 12.3.1.1, and 12.9.1.1, orsequences having changes from said CDR sequences selected from the groupconsisting of conservative changes, wherein the conservative changes areselected from the group consisting of replacement of nonpolar residuesby other nonpolar residues, replacement of polar charged residues otherpolar uncharged residues, replacement of polar charged residues by otherpolar charged residues, and substitution of structurally similarresidues; non-conservative substitutions, wherein the non-conservativesubstitutions are selected from the group consisting of substitution ofpolar charged residue for polar uncharged residues and substitution ofnonpolar residues for polar residues, additions and deletions.

In a further embodiment of the invention, the antibody contains fewerthan 10, 7, 5, or 3 amino acid changes from the germline sequence in theframework or CDR regions. In another embodiment, the antibody containsfewer than 5 amino acid changes in the framework regions and fewer than10 changes in the CDR regions. In one preferred embodiment, the antibodycontains fewer than 3 amino acid changes in the framework regions andfewer than 7 changes in the CDR regions. In a preferred embodiment, thechanges in the framework regions are conservative and those in the CDRregions are somatic mutations.

In another embodiment, the antibody has at least 80%, more preferably,at least 85%, even more preferably, at least 90%, yet more preferably,at least 95%, more preferably, at least 99%, sequence identity over theheavy and light chain CDR1, CDR2 and CDR3 sequences with the CDRsequences of antibody 3.1.1, 4.1.1, 4.8.1, 4.10.2, 4.13.1, 4.14.3,6.1.1, 11.2.1, 11.6.1, 11.7.1, 12.3.1.1, and 12.9.1.1. Even morepreferably, the antibody shares 100% sequence identity over the heavyand light chain CDR1, CDR2 and CDR3 with the sequence of antibody 3.1.1,4.1.1, 4.8.1, 4.10.2, 4.13.1, 4.14.3, 6.1.1, 11.2.1, 11.6.1, 11.7.1,12.3.1.1, and 12.9.1.1.

In yet another embodiment, the antibody has at least 80%, morepreferably, at least 85%, even more preferably, at least 90%, yet morepreferably, at least 95%, more preferably, at least 99%, sequenceidentity over the heavy and light chain variable region sequences withthe variable region sequences of antibody 3.1.1, 4.1.1, 4.8.1, 4.10.2,4.13.1, 4.14.3, 6.1.1, 11.2.1, 11.6.1, 11.7.1, 12.3.1.1, and 12.9.1.1.Even more preferably, the antibody shares 100% sequence identity overthe heavy and light chain variable region sequences with the sequencesof antibody 3.1.1, 4.1.1, 4.8.1, 4.10.2, 4.13.1, 4.14.3, 6.1.1, 11.2.1,11.6.1, 11.7.1, 12.3.1.1, and 12.9.1.1.

D. Other Checkpoint Inhibitors

In addition to those listed above, other checkpoints are known in theart and their inhibitors are included in the invention. For example,BTLA provides a negative signal in response to HVEM, and TIM3 provides anegative signal in response to Ga19. Adenosine can trigger suppressiveeffects through the adenosine A2a receptor, and IDO and TDO are wellknown immunosuppressive pathways thought to be involved in anti-tumorimmunity. LAG3 binds to MHC class II with higher affinity than CD4. LAG3negatively regulates cellular proliferation, activation, and homeostasisof T cells, in a fashion similar to CTLA-4 and PD-1, and it has beenreported to play a role in Treg suppressive function. LAG3 also helpsmaintain CD8⁺ T cells in a tolerogenic state and, working with PD-1,helps maintain CD8 exhaustion during chronic viral infection. LAG3 isknown to be involved in the maturation and activation of dendriticcells. Additional checkpoint inhibitors for use in the inventioninclude, without limitation, antibodies and antigen-binding fragmentsthereof, capable of binding specifically to any one or more of BTLA,TIM3, and LAG3. Also contemplated by the invention are bispecificantibodies and bispecific antigen-binding fragments thereof which arecapable of binding specifically to any one or more of BTLA, TIM3, andLAG3.

The invention contemplates combinations of a TLR9 agonist and acheckpoint inhibitor, where the checkpoint inhibitor can be a single CPIor any combination of two or more CPI. While it is likely that inclinical use only one or only a pair of CPI will be used, the inventioncontemplates using any one, any two, any three, or any four or more CPIselected from, for example, inhibitors of CTLA-4, PD-1, PD-L1, TIM3,LAG3, or BTLA.

E. Origin of Antibodies

While the anti-PD-1, anti-PD-L1, and anti-CTLA-4 antibodies discussedpreviously herein may be preferred, the skilled artisan, based upon thedisclosure provided herein, would appreciate that the inventionencompasses a wide variety of anti-PD-1, anti-PD-L1, and anti-CTLA-4antibodies and is not limited to these particular antibodies. Moreparticularly, while human antibodies are preferred for use in humans,the invention is in no way limited to human antibodies; rather, theinvention encompasses useful antibodies regardless of species origin,and includes, among others, chimeric humanized and/or primatizedantibodies. Also, although certain of the antibodies exemplified hereinwere obtained using a transgenic mammal, e.g., a mouse comprising ahuman immune repertoire, the skilled artisan, based upon the disclosureprovided herein, would understand that the present disclosure is notlimited to an antibody produced by this or by any other particularmethod. Instead, the invention includes an anti-PD-1, anti-PD-L1, oranti-CTLA-4 antibody produced by any method, including, but not limitedto, a method known in the art (e.g., screening phage display libraries,and the like) or to be developed in the future for producing ananti-PD-1, anti-PD-L1, or anti-CTLA-4 antibody of the invention. Basedupon the extensive disclosure provided herein and in, e.g., U.S. Pat.No. 6,682,736 to Bedian et al., and U.S. Pat. App. Pub. No.2002/0088014, one skilled in the art can readily produce and identify ananti-PD-1, anti-PD-L1, or anti-CTLA-4 antibody useful for treatment ofcancer in combination with a CpG ODN using the novel methods disclosedherein.

The present disclosure encompasses human antibodies produced using atransgenic non-human mammal, i.e., XenoMouse™ (Abgenix, Inc., Fremont,Calif.) as disclosed in the U.S. Pat. No. 6,682,736, to Hanson et al.

Another transgenic mouse system for production of “human” antibodies isreferred to as “HuMAb-Mouse™” (Medarex, Princeton, N.J.), which containhuman immunoglobulin gene miniloci that encode unrearranged human heavy(mu and gamma) and kappa light chain immunoglobulin sequences, togetherwith targeted mutations that inactivate the endogenous mu and kappachain loci (Lonberg et al. Nature 368:856-859 (1994), and U.S. Pat. No.5,770,429).

However, the invention uses human anti-PD-1, anti-PD-L1, or anti-CTLA-4antibodies produced using any transgenic mammal such as, but not limitedto, the Kirin TC Mouse™ (Kirin Beer Kabushiki Kaisha, Tokyo, Japan) asdescribed in, e.g., Tomizuka et al., Proc Natl Acad Sci USA 97:722(2000); Kuroiwa et al., Nature Biotechnol 18:1086 (2000); U.S. PatentApplication Publication No. 2004/0120948, to Mikayama et al.; and theHuMAb-Mouse™ (Medarex, Princeton, N.J.) and XenoMouse™ (Abgenix, Inc.,Fremont, Calif.), supra. Thus, the invention encompasses using ananti-PD-1, anti-PD-L1, or anti-CTLA-4 antibody produced using anytransgenic or other non-human animal.

Moreover, while the preferred method of producing a human anti-PD-1,anti-PD-L1, or anti-CTLA-4 antibody comprises generation of theantibodies using a non-human transgenic mammal comprising a human immunerepertoire, the present disclosure is in no way limited to thisapproach. Rather, as would be appreciated by one skilled in the art oncearmed with the disclosure provided herein, the invention encompassesusing any method for production of a human, or any other antibodyspecific for PD-1, PD-L1, or CTLA-4 produced according to any methodknown in the art or to be developed in the future for production ofantibodies that specifically bind an antigen of interest

Human antibodies can be developed by methods that include, but are notlimited to, use of phage display antibody libraries. For example, usingthese techniques, antibodies can be generated to CTLA-4-expressingcells, CTLA-4 itself, forms of CTLA-4, epitopes or peptides thereof, andexpression libraries thereto (see e.g. U.S. Pat. No. 5,703,057), whichcan thereafter be screened for the activities described above.

In another embodiment, the antibodies employed in methods of theinvention are not fully human, but “humanized”. In particular, murineantibodies or antibodies from other species can be “humanized” or“primatized” using techniques well known in the art. See, e.g., Winterand Harris Immunol. Today 14:43-46 (1993), Wright et al. Crit. Reviewsin Immunol. 12:125-168 (1992), and U.S. Pat. No. 4,816,567, to Cabillyet al., and Mage and Lamoyi in Monoclonal Antibody Production Techniquesand Applications pp. 79-97, Marcel Dekker, Inc., New York, N.Y. (1987).

As will be appreciated based upon the disclosure provided herein,antibodies for use in the invention can be obtained from a transgenicnon-human mammal, and hybridomas derived therefrom, but can also beexpressed in cell lines other than hybridomas.

Mammalian cell lines available as hosts for expression are well known inthe art and include many immortalized cell lines available from theAmerican Type Culture Collection (ATCC), including but not limited toChinese hamster ovary (CHO) cells, NSO, HeLa cells, baby hamster kidney(BHK) cells, monkey kidney cells (COS), and human hepatocellularcarcinoma cells (e.g., Hep G2). Non-mammalian prokaryotic and eukaryoticcells can also be employed, including bacterial, yeast, insect, andplant cells.

Various expression systems can be used as well known in the art, suchas, but not limited to, those described in e.g., Sambrook and Russell,Molecular Cloning, A Laboratory Approach, Cold Spring Harbor Press, ColdSpring Harbor, N.Y. (2001), and Ausubel et al., Current Protocols inMolecular Biology, John Wiley & Sons, NY (2002). These expressionsystems include dihydrofolate reductase (DHFR)-based systems, among manyothers. The glutamine synthetase system of expression is discussed inwhole or part in connection with European Patents Nos. EP 216 846, EP256 055, and EP 323 997 and European Patent Application 89303964. In oneembodiment, the antibody used is made in NSO cells using a glutaminesynthetase system (GS-NSO). In another embodiment, the antibody is madein CHO cells using a DHFR system. Both systems are well-known in the artand are described in, among others, Barnes et al. Biotech &Bioengineering 73:261-270 (2001), and references cited therein.

Site-directed mutagenesis of the antibody CH2 domain to eliminateglycosylation may be preferred in order to prevent changes in either theimmunogenicity, pharmacokinetic, and/or effector functions resultingfrom non-human glycosylation. Further, the antibody can bedeglycosylated by enzymatic (see, e.g., Thotakura et al. Meth. Enzymol.138:350 (1987)) and/or chemical methods (see, e.g., Hakimuddin et al.,Arch. Biochem. Biophys. 259:52 (1987)).

Further, the invention encompasses using an anti-PD-1 antibody,anti-PD-L1 antibody, or anti-CTLA-4 antibody comprising an alteredglycosylation pattern. The skilled artisan would appreciate, based uponthe disclosure provided herein, that an anti-PD-1 antibody, anti-PD-L1antibody, or anti-CTLA-4 antibody can be modified to compriseadditional, fewer, or different glycosylation sites compared with thecorresponding unaltered antibody. Such modifications are described in,e.g., U.S. Patent Application Publication Nos. 2003/0207336, and2003/0157108, and International Patent Publication Nos. WO 01/81405 and00/24893.

Additionally, the invention comprises using an anti-PD-1 antibody,anti-PD-L1 antibody, or anti-CTLA-4 antibody regardless of theglycoform, if any, present on the antibody. Moreover, methods forextensively remodeling the glycoform present on a glycoprotein arewell-known in the art and include, e.g., those described inInternational Patent Publication Nos. WO 03/031464, WO 98/58964, and WO99/22764, and US Patent Application Publication Nos. 2004/0063911,2004/0132640, 2004/0142856, 2004/0072290, and U.S. Pat. No. 6,602,684 toUmana et al.

Further, the invention encompasses using an anti-PD-1 antibody,anti-PD-L1 antibody, or anti-CTLA-4 antibody with any art-known covalentand non-covalent modification, including, but not limited to, linkingthe polypeptide to one of a variety of nonproteinaceous polymers, e.g.,polyethylene glycol, polypropylene glycol, or polyoxyalkylenes, in themanner set forth in, for example, U.S. Patent Application PublicationNos. 2003/0207346 and 2004/0132640, and U.S. Pat. Nos. 4,640,835;4,496,689; 4,301,144; 4,670,417; 4,791,192; and 4,179,337.

Additionally, the invention encompasses using an anti-PD-1 antibody,anti-PD-L1 antibody, or anti-CTLA-4 antibody, or antigen-binding portionthereof, chimeric protein comprising, e.g., a human serum albuminpolypeptide, or fragment thereof. Whether the chimeric protein isproduced using recombinant methods by, e.g., cloning of a chimericnucleic acid encoding the chimeric protein, or by chemical linkage ofthe two peptide portions, the skilled artisan would understand oncearmed with the teachings provided herein that such chimeric proteins arewell-known in the art and can confer desirable biological propertiessuch as, but not limited to, increased stability and serum half-life tothe antibody of the invention and such molecules are therefore includedherein.

Antibodies that are generated for use in the invention need notinitially possess a particular desired isotype. Rather, the antibody asgenerated can possess any isotype and can be isotype switched thereafterusing conventional techniques. These include direct recombinanttechniques (see, e.g., U.S. Pat. No. 4,816,397), and cell-cell fusiontechniques (see e.g., U.S. Pat. No. 5,916,771).

The effector function of the antibodies of the invention may be changedby isotype switching to an IgG1, IgG2, IgG3, IgG4, IgD, IgA, IgE, or IgMfor various therapeutic uses. Furthermore, dependence on complement forcell killing can be avoided through the use of bispecifics,immunotoxins, or radiolabels, for example.

Therefore, while the preferred anti-CTLA-4 antibodies used in theinvention are exemplified by antibodies having the amino acid sequencesof 3.1.1, 4.1.1, 4.8.1, 4.10.2, 4.13.1, 4.14.3, 6.1.1, 11.2.1, 11.6.1,11.7.1, 12.3.1.1, 12.9.1.1, and MDX-010, or, e.g., the sequences of theV regions or CDRs thereof, the present disclosure is not limited in anyway to using these, or any other, particular anti-CTLA-4 antibodies.Preferably, the antibody is 4.1.1, 4.13.1, 11.2.1, and/or MDX-010.However, any anti-CTLA-4 antibody, or antigen-binding portion thereof,as described elsewhere herein, or as known in the art or developed inthe future, can be used in a method of the invention. More particularly,humanized chimeric antibodies, anti-CTLA-4 antibodies derived from anyspecies (including single chain antibodies obtained from camelids asdescribed in, e.g., U.S. Pat. Nos. 5,759,808 and 6,765,087, to Castermanand Hamers), as well as any human antibody, can be combined with a CpGODN to practice the novel methods disclosed herein.

The invention also encompasses such antibodies as disclosed in, interalia, International Patent Publication Nos. WO 00/37504 (published Jun.29, 2000); WO 01/14424 (published Mar. 1, 2001); WO 93/00431 (publishedJan. 7, 1993); and WO 00/32231 (published Jun. 8, 2000), among manyothers.

Thus, the skilled artisan, once provided with the teachings providedherein, would readily appreciate that the anti-CTLA-4antibody-therapeutic agent combination of the invention can comprise awide plethora of anti-CTLA-4 antibodies.

Further, one skilled in the art, based upon the disclosure providedherein, would understand that the invention is not limited toadministration of only a single antibody; rather, the inventionencompasses administering at least one anti-CTLA-4 antibody, e.g.,4.1.1, 4.13.1 and 11.2.1, in combination with a CpG ODN. Moreover, theinvention encompasses administering any combination of any knownanti-CTLA-4 antibody, including, but not limited to, administering a CpGODN in combination with, e.g., 4.1.1, 4.13.1, 11.2.1 and MDX-010. Thus,any combination of anti-CTLA-4 antibodies can be combined with at leastone therapeutic agent and the present disclosure encompasses any suchcombination and permutation thereof.

IV. Cpg DNA and Checkpoint Inhibitor Combination Immunotherapy

The present disclosure relates to combination tumor immunotherapycomprising locally administering CpG ODN into or in proximity to acancerous tumor, and systemically administering a checkpoint inhibitor,such as an anti-PD-1 antibody, an anti-PD-L1 antibody, or an anti-CTLA-4antibody, to treat cancer. A single human clinical trial has beenreported in which patients were treated with a combination of a CpG ODN(B-class, dosed subcutaneously up to 0.15 mg/kg/wk) and an anti-CTLA-4antibody (Millward M et al., Br. J. Cancer 2013 108(10): 1998-2004).This study established an MTD for a weekly combination of IV anti-CTLA-4and subcutaneous CpG over 12 weeks of therapy in 21 patients with stageIV melanoma. Although the results of the study were not consideredencouraging enough to warrant continued development of TLR9 agonists inoncology (all immune-oncology drug development by the sponsor wasterminated), several interesting findings from the study support theutility of the present disclosure. First, the combination of a TLR9agonist and a checkpoint inhibitor is relatively well tolerated—therewas no observed systemic autoimmune disease, and only three patientsdeveloped dose-limiting toxicities during the pre-specified initial 6week period, two of whom were in the highest dose group of theanti-CTLA-4 antibody. Second, there was no induction of antibodyresponse against the anti-CTLA-4 antibody from the combination regimen.Third, two patients achieved partial responses to the treatment, andseveral others had unusually prolonged stable disease.

Combination of high IFN-inducing CpG ODN and anti-PD-1, anti-PD-L1, oranti-CTLA-4 is useful for treatment of primary and secondary (i.e.,metastatic) cancers. More specifically, among many potential treatmentoptions, CpG ODN and anti-checkpoint combination therapy can be used totreat cancer. In certain embodiments, the cancer to be treated is orincludes a cancerous tumor. A “cancerous tumor” as used herein refers toan abnormal swelling or macroscopic collection of cells comprisingabnormal cells characterized by their growth or proliferation withoutregulation by normal external signals. In certain embodiments, acancerous tumor is a carcinoma, sarcoma, or adenocarcinoma; these aresometimes referred to as solid tumors. In certain embodiments, acancerous tumor excludes hematologic malignancies. In certainembodiments, a cancerous tumor includes certain hematologicmalignancies, e.g., lymphomas.

Representative cancers treatable by the methods of the presentdisclosure (e.g., methods of treating cancer by administration of one ormore CpG-ODN alone or in combination with one or more CPI) specificallyinclude, without limitation, cancers of skin, head and neck, esophagus,stomach, liver, colon, rectum, pancreas, lung, breast, cervix, ovary,kidney, bladder, prostate, thyroid, brain, muscle, and bone. Alsospecifically included among cancers treatable by the methods of theinvention are melanoma, renal cell carcinoma, and non-small cell lungcancer (NSCLC). Also specifically included among cancers treatable bythe methods of the invention are lymphoma, cancer of the bone marrow,carcinoid tumor, and neuroblastoma.

While in some embodiments the foregoing cancers are preferred, thepresent disclosure relates to treatment of a wide variety of malignantcell proliferative disorders, including, but not limited to Kaposi'ssarcoma, synovial sarcoma, mesothelioma, hepatobiliary (hepatic andbiliary duct), a primary or secondary brain tumor, lung cancer (NSCLCand SCLC), bone cancer, skin cancer, cancer of the head or neck,cutaneous or intraocular melanoma, cancer of the anal region, stomach(gastric) cancer, gastrointestinal (gastric, colorectal, and duodenal)cancer, colon cancers, uterine cancer, carcinoma of the fallopian tubes,carcinoma of the endometrium, carcinoma of the cervix, carcinoma of thevagina, carcinoma of the vulva, cancer of the esophagus, cancer of thesmall intestine, cancer of the endocrine system, cancer of the thyroidgland, cancer of the parathyroid gland, cancer of the adrenal gland,sarcoma of soft tissue, cancer of the urethra, prostate cancer, cancerof the penis, testicular cancer, cancer of the bladder, cancer of thekidney or ureter, carcinoma of the renal pelvis, pancreatic cancers,neoplasms of the central nervous system (CNS) including primary orsecondary CNS tumor, spinal axis tumors, brain stem glioma,glioblastoma, meningioma, myoblastoma, astrocytoma, pituitary adenoma,adrenocortical cancer, gall bladder cancer, cholangiocarcinoma,fibrosarcoma, neuroblastoma, and retinoblastoma; as well as, in someembodiments, non-Hodgkin's lymphoma (NHL, including indolent andaggressive), Hodgkin's lymphoma, cutaneous T-cell lymphoma, lymphocyticlymphomas, primary CNS lymphoma, chronic or acute myeloid leukemia,chronic or acute lymphocytic leukemia, erythroblastoma, and multiplemyeloma; or a combination of two or more of the foregoing cancers.

The cancers to be treated may be refractory cancers. A refractory canceras used herein is a cancer that is resistant to the ordinary standard ofcare prescribed. These cancers may appear initially responsive to atreatment (and then recur), or they may be completely non-responsive tothe treatment. The ordinary standard of care will vary depending uponthe cancer type, and the degree of progression in the subject. It may bea chemotherapy, an immunotherapy, surgery, radiation, or a combinationthereof. Those of ordinary skill in the art are aware of such standardsof care. Subjects being treated according to the invention for arefractory cancer therefore may have already been exposed to anothertreatment for their cancer. Alternatively, if the cancer is likely to berefractory (e.g., given an analysis of the cancer cells or history ofthe subject), then the subject may not have already been exposed toanother treatment.

In certain embodiments, refractory cancers include cancers which arerefractory to treatment with a checkpoint inhibitor. Cancers of thistype are sometimes referred to as “cold”. Methods of the instantinvention can be used to treat such “cold” cancers or tumors to convertthem into “hot” ones, i.e., cancers or tumors which respond totreatment, including treatment with a checkpoint inhibitor, even thesame checkpoint inhibitor.

Examples of refractory cancers include but are not limited to melanomas,renal cell carcinomas, colon cancer, liver (hepatic) cancers, pancreaticcancer, non-Hodgkin's lymphoma, lung cancer, and leukemias.

The methods of the invention in certain instances may be useful forreplacing existing surgical procedures or drug therapies, although inother instances the present disclosure is useful in improving theefficacy of existing therapies for treating such conditions. Accordinglycombination therapy may be used to treat subjects that are undergoing orthat will undergo a treatment for cancer. For example, the agents may beadministered to a subject in combination with another anti-proliferative(e.g., an anti-cancer) therapy. Suitable anti-cancer therapies includesurgical procedures to remove the tumor mass, chemotherapy, or localizedradiation. The other anti-proliferative therapy may be administeredbefore, concurrent with, or after treatment with the CpG ODN/CPIcombination of the invention. There may also be a delay of severalhours, days, and in some instances weeks between the administration ofthe different treatments, such that the CpG ODN/CPI combination may beadministered before or after the other treatment. The invention furthercontemplates the use of the CpG ODN/CPI combination in cancer subjectsprior to and following surgery, radiation or chemotherapy.

In one embodiment, the invention provides compositions and methods ofproducing or increasing an anti-tumor response using a CpG ODN-CPIcombination, wherein CpG ODN enhances an anti-tumor response by anamount of CPI which is otherwise sub-optimal for inducing the same levelof anti-tumor response when used alone. In certain embodiments, when theCpG ODN is not used in conjunction with a CPI to elicit an anti-tumorresponse, administering CpG ODN alone does not produce or increase theanti-tumor response. In alternate embodiments, both the CpG ODN and theCPI can elicit an anti-tumor response alone and/or when administered incombination.

In one embodiment, the invention provides compositions and methods ofproducing or increasing an anti-tumor response using a CpG ODN-CPIantibody combination, wherein CpG ODN enhances an anti-tumor response byan amount of antibody which is otherwise sub-optimal for inducing thesame level of anti-tumor response when used alone. In certainembodiments, when the CpG ODN is not used in conjunction with a CPIantibody to elicit an anti-tumor response, administering CpG ODN alonedoes not produce or increase the anti-tumor response. In alternateembodiments, both the CpG ODN and the CPI antibody can elicit ananti-tumor response alone and/or when administered in combination.

In certain embodiments, the CpG ODN may enhance the effects of the CPI(or vice-versa) in an additive manner. In a preferred embodiment, theCpG ODN enhances the effects of the CPI (or vice versa) in a synergisticmanner. In another embodiment, the CPI enhances the effect of a CpG ODNin an additive manner. Preferably, the effects are enhanced in asynergistic manner. Thus, in certain embodiments, the inventionencompasses methods of disease treatment or prevention that providebetter therapeutic profiles than expected based on administration of CpGODN alone and CPI alone.

In certain embodiments, the CpG ODN may enhance the effects of the CPIantibody (or vice-versa) in an additive manner. In a preferredembodiment, the CpG ODN enhances the effects of the CPI antibody (orvice versa) in a synergistic manner. In another embodiment, the CPIantibody enhances the effect of a CpG ODN in an additive manner.Preferably, the effects are enhanced in a synergistic manner. Thus, incertain embodiments, the invention encompasses methods of diseasetreatment or prevention that provide better therapeutic profiles thanexpected based on administration of CpG ODN alone and CPI antibodyalone.

In certain embodiments, the CpG ODN is administered with CPI (with orwithout other modalities such as radiotherapy) as a part of aneoadjuvant therapeutic regimen to achieve an anti-tumor effect thatwill make possible curative surgery.

In certain embodiments, the CpG ODN is administered together with CPI(with or without other modalities such as radiotherapy) followingsurgical resection of a primary or metastatic tumor or in the setting ofminimal residual disease in order to prevent tumor recurrence.

Also encompassed by the invention are combination therapies that haveadditive potency or an additive therapeutic effect while reducing oravoiding unwanted or adverse effects. The invention also encompassessynergistic combinations where the therapeutic efficacy is greater thanadditive, while unwanted or adverse effects are reduced or avoided. Incertain embodiments, the methods of the invention permit treatment orprevention of diseases and disorders wherein treatment is improved by anenhanced anti-tumor response using lower and/or less frequent doses ofCpG ODN and/or CPI to reduce the incidence of unwanted or adverseeffects caused by the administration of CpG ODN alone and/or CPI alone,while maintaining or enhancing efficacy of treatment, preferablyincreasing patient compliance, improving therapy, and/or reducingunwanted or adverse effects.

V. Additional Combination Therapy

Methods of the invention can be used in conjunction with otheranti-cancer therapies, including chemotherapy, other immunotherapy,radiotherapy, hormone therapy, and the like. Conventionalchemotherapeutics and targeted antineoplastic agents have been developedbased on the simplistic notion that cancer constitutes a cell-autonomousgenetic or epigenetic disease. However, it is becoming clear that manyof the available anticancer drugs that have collectively saved millionsof life-years mediate therapeutic effects by eliciting de novo orreactivating pre-existing tumor-specific immune responses. Accumulatingevidence indicates that the therapeutic efficacy of severalantineoplastic agents relies on their capacity to influence thetumor-host interaction, tipping the balance toward the activation of animmune response specific for malignant cells.

For example, Table 1 lists certain FDA-approved anticancer agents whoseefficacy is reduced by immune deficiencies (Zitvogel L. et al., Immunity2013 39(1):74-88).

TABLE 1 Agent Tumor Immune Defects 5-fluorouracil EL4 lymphomas Nu/Nugenotype anthracyclines CT26 colorectal carcinomas, Nu/Nu genotype,depletion MCA205 fibrosarcomas, of CD8⁺ or γ/δ T cells, MCA-inducedtumors blockade of CD11b, neutralization of IL-1, IL- 17, or IFN-γ ATRA± arsenic trioxide murine APLs SCID phenotype arsenic trioxide CT26colorectal cancers Nu/Nu genotype cisplatin + digoxin MCA205fibrosarcomas Nu/Nu genotype cyclophosphamide AB1-HA mesotheliomasIfngr2^(-/-), Tnfsfl10^(-/-), depletion of CD8⁺ T cells or NK cellsdasatinib P815 mastocytomas depletion of CD4⁺ or CD8⁺ T cellsgemcitabine AB12 mesotheliomas, EJ-6- Nu/Nu genotype 2 fibrosarcomas,EL4 lymphomas, TC1 insulinomas imatinib AK7 mesotheliomas, B16 depletionof NK cells melanomas, RMA-S Rag1^(-/-), depletion of CD8⁺ T lymphomascells GISTs developing in Kit^(V558/+) mice mitomycin C + digoxin MCA205fibrosarcomas Nu/Nu genotype oxaliplatin CT26 colorectal carcinomas,Nu/Nu genotype MCA205 fibrosarcomas paclitaxel Ret-driven melanomasdepletion of CD8⁺ T cells PLX4720 (BRAF inhibitor) SM1WT1 melanomasCcr2^(-/-), Ifng^(-/-), Prf1^(-/-), depletion of CD8⁺ T cells Table 1Abbreviations: APL, acute promyelocytic leukemia; ATRA, all-transretinoic acid; BRAF, B-Raf; GIST, gastrointestinal stromal tumor; IFN,interferon; IL, interleukin; MCA, 3-methylcholanthrene; NK, naturalkiller; SCID, severe combined immunodeficient

VI. Dosage Regimens

Dosage regimens can be adjusted to provide the optimum desired response.For example, a single bolus can be administered, several divided dosescan be administered over time, or the dose may be proportionally reducedor increased as indicated by the exigencies of the therapeuticsituation. It is especially advantageous to formulate parenteralcompositions in dosage unit form for ease of administration anduniformity of dosage. Dosage unit form as used herein refers tophysically discrete units suited as unitary dosages for the mammaliansubjects to be treated; each unit containing a predetermined quantity ofactive compound calculated to produce the desired therapeutic effect inassociation with the required pharmaceutical carrier. The specificationfor the dosage unit forms of the invention are dictated by and directlydependent on (a) the unique characteristics of the active compound andthe particular therapeutic or prophylactic effect to be achieved, and(b) the limitations inherent in the art of compounding such an activecompound for the treatment of sensitivity in individuals.

Thus, the skilled artisan would appreciate, based upon the disclosureprovided herein, that the dose and dosing regimen is adjusted inaccordance with methods well-known in the therapeutic arts. That is, themaximum tolerable dose can be readily established, and the effectiveamount providing a detectable therapeutic benefit to a patient can alsobe determined, as can the temporal requirements for administering eachagent to provide a detectable therapeutic benefit to the patient.Accordingly, while certain dose and administration regimens areexemplified herein, these examples in no way limit the dose andadministration regimen that can be provided to a patient in practicingthe present disclosure. Further, one skilled in the art wouldunderstand, once armed with the teachings provided herein, that atherapeutic benefit, such as, but not limited to, detectable decrease intumor size and/or metastasis, and increased time to recurrence, amongmany other parameters, can be assessed by a wide variety of methodsknown in the art for assessing the efficacy of treatment of cancer, andthese methods are encompassed herein, as well as methods to be developedin the future.

It is to be noted that dosage values may vary with the type and severityof the condition to be alleviated, and may include single or multipledoses. It is to be further understood that for any particular subject,specific dosage regimens should be adjusted over time according to theindividual need and the professional judgment of the personadministering or supervising the administration of the compositions, andthat dosage ranges set forth herein are exemplary only and are notintended to limit the scope or practice of the claimed composition. Forexample, doses may be adjusted based on pharmacokinetic orpharmacodynamic parameters, which may include clinical effects such astoxic effects and/or laboratory values. Thus, the present disclosureencompasses intra-patient dose-escalation as determined by the skilledartisan. Determining appropriate dosages and regimens for administrationof the active compound or compounds are well-known in the relevant artand would be understood to be encompassed by the skilled artisan onceprovided the teachings disclosed herein.

In various embodiments of the present disclosure, a prime-boost dosingregimen is employed that includes one or multiple administrations of aspecific volume of a first composition comprising one or more CpG-ODN(e.g., a CpG-A ODN, optionally where one or more of the ODN areformulated in a VLP) via a specific route (i.e., a “prime”), followed byone or multiple administrations of a specific volume of a secondcomposition comprising either one or more CpG-ODN (e.g., a CpG-A ODN,optionally where one or more of the ODN are formulated in a VLP) or oneor more CPI via a specific route (i.e., a “boost”).

In various embodiments of the present disclosure, where the CpG-A ODN isformulated with a VLP, the first dose of VLP induces an antibodyresponse to the VLP coat protein. For example, if the CpG-A G10 isformulated with the Qb bacteriophage coat protein to produce CMP-001(formerly known as CYT003 or QbG10), then human dosing results in theproduction of antibodies to the VLP protein, Qb.

CpG-A ODN that are not encapsulated in a VLP can be taken up directly bypDC through ODN receptors. This approach to therapy is effective if theODN has one or more phosphorothioate linkages protecting the 5′ and/orthe 3′ ends of the ODN against degradation. Preferred embodiments ofCpG-A ODN for direct injection without a VLP have at least 1, andpreferably 2 phosphorothioate linkages at the 5′ and 3′ ends, andespecially preferred embodiments have 3, 4, or 5 phosphorothioatelinkages at the 3′ end of the ODN.

However, CpG-A ODN that have no phosphorothioate linkages at all canstill be used quite effectively for therapy, especially if they arepacked into a VLP, or otherwise protected against degradation using anyof the many formulations and delivery systems known to those expert inthe art of oligonucleotide therapeutics. Some CpG-A ODN delivery systemscan be taken up directly by pDC, but the Qb VLP delivery system usede.g., in CMP-001, requires the presence of anti-Qb antibodies toopsonize the VLP so that it may be taken up by the pDC via the Fcreceptor that is expressed on the pDC, FcgRIIa. Because the VLP isextremely immunogenic, the initial injection of CMP-001 throughintratumoral, SC or other route of administration, induces theproduction of high titer opsonizing antibodies as early as 1 week afterthe initial injection (the “priming” dose). This priming dose simplyneeds to be large enough in a human to induce the antibody response,which can be achieved with a dose of at least 100 ug, and morepreferably at least 300 ug. In some embodiments the priming dose is 1 mgand in other embodiments is more than 1 mg, including most preferablydoses up to 10 mg. Following the priming dose, the 2^(nd), 3^(rd), andsubsequent injections of the VLP containing the CpG-A are rapidlyopsonized by the pre-existing anti-Qb antibody in the serum and tissues,leading to the uptake of the VLP into pDC (in which TLR9 is activated,inducing type I IFN production). These subsequent injections may begiven at a frequency of daily, weekly, monthly, or any intermediatefrequency of administration, and for durations of weeks, months, oryears of therapy, as needed for the treatment of a patient.

It will be appreciated by those of ordinary skill in the art thatprime-boost methods and compositions thereof and described herein may beaccomplished by employing a variety of different regimens. In variousembodiments, certain regimens may include multiple (i.e., one, two,three, four, or five) priming administrations, and/or multiple (i.e.,one, two, three, four, or five) boosting administrations, and/ormultiple (i.e., one, two, three, four, or five) secondary boostingadministrations.

In some embodiments, methods contemplated herein comprise administeringthe compositions (e.g., composition comprising CpG and/or CPI) more thanonce to the subject. In particular embodiments, a composition isadministered at least two, at least three, at least four, at least five,or more times (e.g., twice (two times), three times, four times, fivetimes, or more) to the subject. Stated another way, multiple doses(i.e., 2, 3, 4, 5, 6, or more doses) of a composition are administeredto the subject. When a first composition is administered multiple times(i.e., twice (two times), three times, four times, five times, or more),each administration of the first composition may be sequential and eachand all administrations of the composition are prior to administrationof a second composition.

As described herein, in other embodiments, compositions (e.g.,composition comprising CpG and/or CPI) may be administered concurrentlyat least once. In one such embodiment, methods are provided herein thatcomprise administering (1) a composition comprising a first CpG andsequentially administering, in either order, (2) a second dose of thecomposition comprising the CpG concurrently with a compositioncomprising a second CpG.

With respect to the methods described herein that include sequentialadministration of compositions (e.g., composition comprising CpG and/orCPI), the time interval between doses can be readily determined by aperson skilled in the art practicing clinical trials. The dosing regimenfor human subjects may also be informed by results from pre-clinicalstudies and knowledge in the art. In certain embodiments, time intervalbetween administration of doses (e.g., a priming, first boost, secondboost, third boost, etc.) of the compositions may be at least one, two,three, four, five, six, or seven days or one, two, three, four, five,six, seven, or eight weeks, or may be at least one, two, three, four,five, six, seven, eight, nine, ten, or eleven months, or at least one,two, three, or four years. The time intervals as described hereinbetween administrations of the same or different compositions pertain toany of the administration regimens described herein.

CpG ODN Dosing

In accordance with the methods of the present disclosure, CpG ODN isadministered locally to the cancerous tumor, i.e., by intratumoral orperitumoral administration. Alternatively or in addition, in certainembodiments CpG ODN is administered locally to the cancerous tumor by,for example, intraperitoneal injection or infusion or intravesicularinstillation.

Most of the prior art with CpG used subcutaneous administration, notintratumoral or peritumoral. Intratumoral therapy in oncology isgenerally preferred only for the treatment of primary lesions, not inthe situation of metastatic disease. The reason for this is that mostintratumoral therapies have only a local effect. In some unusual cases,intratumoral therapies can lead to regression of distant tumor masses asa result of the induction of a specific immune response against tumorantigens present not only in the injected lesion, but also in distantmetastases. In the case of radiotherapy (XRT), this has been termed an“abscopal effect” as described above. Some authors have noted cases inwhich abscopal effects have been induced by TLR agonists, includingintratumoral TLR9 (Brody et al, J. Clin. Oncol. 2010 28(28): 4324-4332;Kim et al., Blood 2012 119(2): 355-363), but these responses have beenuncommon and generally of brief duration.

The immune effects of XRT given prior to CpG ODN administration willdisrupt the inhibitory mechanisms that normally limit the efficacy ofthe CpG-induced response, increasing the potential for clinicalresponse. In addition, the production of IFN-α in the tumor has beenassociated with and is required for an improved response to XRT(Burnette et al, Cancer Res. 2011 71: 2488-2496), providing furtherevidence for benefit from the use of intratumoral high IFN CpG followingXRT.

In one form, the present disclosure comprises a method for improving theinduction of abscopal responses from XRT by administering XRT,preferably hypofractionated XRT (as described in Prasanna et al.), to acancer patient and then administering an intratumoral or peritumoralhigh IFN-inducing CpG ODN in the same region or lymphatic drainage.Preferred peritumoral injections are in the same lymphatic drainage asthe tumor, in order to facilitate that the same APC are exposed both tothe tumor Ag released following XRT to the tumor, and to the TLR ligand.

Methods of intratumoral or peritumoral delivery of CpG ODN include notonly direct injection, but also can include topical deliveryintraperitoneal delivery for abdominal tumors such as ovarian,pancreatic, colon, or gastric), intraocular for eye malignancies, oralfor gastric and intestinal cancer, and intravesicular administration forbladder cancer. Also contemplated for intratumoral administration of CpGODN is systemic delivery using tumor delivery vehicles such astumor-targeted aptamers, antibody conjugates, nanoparticles, ISCOMS,VLP, multilaminar vesicles, pH-sensitive peptides, and cationicpeptides.

For systemic therapy, CpG ODN can be variably dosed based on weight,body surface area, or using a fixed dose. For intratumoral orperitumoral administration, the CpG ODN dose typically is fixed. Dosesof CpG ODN for parenteral (including intratumoral and peritumoral)delivery for inducing an immune response when CpG ODN is administered incombination with other therapeutic agents, such as the CPI of theinvention, typically range from about 1 μg to 100 mg per administration,which depending on the application could be given daily, weekly, ormonthly and any other amount of time therebetween.

In certain embodiments, subject doses of CpG ODN for intratumoral andperitumoral delivery typically range from about 10 μg to about 100 mgper administration, which depending on the application could be givendaily, weekly, or monthly and any other amount of time therebetween. Incertain embodiments, subject doses of CpG ODN for intratumoral andperitumoral delivery typically range from about 100 μg to about 100 mgper administration, which depending on the application could be givendaily, weekly, or monthly and any other amount of time therebetween. Incertain embodiments, subject doses of CpG ODN for intratumoral andperitumoral delivery typically range from about 1 mg to about 100 mg peradministration, which depending on the application could be given daily,weekly, or monthly and any other amount of time therebetween. In certainembodiments, subject doses of CpG ODN for intratumoral and peritumoraldelivery typically range from about 10 mg to about 100 mg peradministration, which depending on the application could be given daily,weekly, or monthly and any other amount of time therebetween.

In yet other embodiments, doses of CpG ODN for parenteral (includingintratumoral and peritumoral) delivery for inducing an immune responsewhen CpG ODN is administered in combination with other therapeuticagents, such as the CPI of the invention, typically range from about 1μg to about 50 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween. In certain embodiments, subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 10 μgto about 50 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween. In certain embodiments, subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 100 μgto about 50 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween. In certain embodiments, subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 1 mg toabout 50 mg per administration, which depending on the application couldbe given daily, weekly, or monthly and any other amount of timetherebetween. In certain embodiments, subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 10 mgto about 50 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween.

In yet other embodiments, doses of CpG ODN for parenteral (includingintratumoral and peritumoral) delivery for inducing an immune responsewhen CpG ODN is administered in combination with other therapeuticagents, such as the CPI of the invention, typically range from about 1μg to about 10 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween. In certain embodiments, subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 10 μgto about 10 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween. In certain embodiments, subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 100 μgto about 10 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween. In certain embodiments, subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 1 mg toabout 10 mg per administration, which depending on the application couldbe given daily, weekly, or monthly and any other amount of timetherebetween.

In yet other embodiments, doses of CpG ODN for parenteral (includingintratumoral and peritumoral) delivery for inducing an immune responsewhen CpG ODN is administered in combination with other therapeuticagents, such as the CPI of the invention, typically range from about 1μg to about 1 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween. In certain embodiments, subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 10 μgto about 1 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween. In certain embodiments, subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 100 μgto about 1 mg per administration, which depending on the applicationcould be given daily, weekly, or monthly and any other amount of timetherebetween.

For each of the fixed doses described above, in certain embodiments thedose of CpG-ODN will be administered in a total volume of greater than 4mL. In certain embodiments, the dose will be administered in a volume4.5, 5, 5, 5, 6, 6.5, 7, 7.5, 8, 8.5, 9, 9.5, 10, 11, 12, 13, 14, 15,16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33,34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 or 50 mL.In various embodiments, the injection may be into a single site, or intomultiple and/or different sites. In some embodiments all of theinjection volume is administered intratumorally into a single tumor. Inother embodiments the injection volume is divided up between 2 or moretumors, equally, or in varying volumes depending on the size of thetumor. In some embodiments the volume is split between 1 or more tumorsand 1 or more peritumoral or subcutaneous sites. In various embodiments,where multiple doses of a CpG-ODN are administered to a subject (e.g.,as part of a prime-boost regimen), each and every dose of the CpG-ODN,including CpG formulated with VLP, is administered in a volume greaterthan 4 mL.

As will be appreciated and as described herein, in certain embodimentsthe “volume” administered can be total volume that is split intomultiple different injected tumors, or a single tumor, and can includesome volume that is injected intratumorally, and some volume injectedperitumorally in the same patient (i.e., the large dose volume ofgreater than 4 mL may be distributed in appropriate fractions toappropriate multiple sites.

In other embodiments, the dose to be administered at a given time is1-50 mL containing a first amount of CpG-ODN and it isadministered/distributed to multiple lesions and/or sites (e.g.,potentially targeting lymph nodes) via intra- and/or peri-tumoral and/orSC injections, such that the total volume administered is greater than 4mL.

In certain embodiments of the invention, a sustained release deliverysystem, including for example nanoparticles, ISCOMS, VLP, and dendrimers(reviewed in, for example, Gomes Dos Santos A L et al., Curr PharmBiotechnol. 2005 6(1): 7-15; Joshi V B et al., AAPS J. 2013 15(1):85-94; and Arima H et al., Curr Top Med Chem. 2014 14(4): 465-77), maybe used to administer a single intratumoral or peritumoral therapeuticdose of the CpG ODN. In certain embodiments of the invention, asustained release delivery system, including for example nanoparticles,ISCOMS, VLP, and dendrimers, may be used to administer a singleintratumoral or peritumoral therapeutic dose of the CpG ODN, with nofurther CpG ODN required.

As is well known in the art, individual doses are increased when using asustained delivery system of any of the types well described in theliterature.

In certain embodiments using a single administration of a sustainedrelease formulation of CpG ODN, the subject dose of CpG ODN forintratumoral and peritumoral delivery typically ranges from about 0.1 mgto about 500 mg per administration, and it is given within one week ofXRT; within one week of a checkpoint inhibitor; or within one week ofboth XRT and a checkpoint inhibitor. In certain embodiments using asingle administration of a sustained release formulation of CpG ODN, thesubject dose of CpG ODN for intratumoral and peritumoral deliverytypically ranges from about 1 mg to about 500 mg per administration, andit is given within one week of XRT; within one week of a checkpointinhibitor; or within one week of both XRT and a checkpoint inhibitor. Incertain embodiments using a single administration of a sustained releaseformulation of CpG ODN, the subject dose of CpG ODN for intratumoral andperitumoral delivery typically ranges from about 10 mg to about 500 mgper administration, and it is given within one week of XRT; within oneweek of a checkpoint inhibitor; or within one week of both XRT and acheckpoint inhibitor. In certain embodiments using a singleadministration of a sustained release formulation of CpG ODN, thesubject dose of CpG ODN for intratumoral and peritumoral deliverytypically ranges from about 100 mg to about 500 mg per administration,and it is given within one week of XRT; within one week of a checkpointinhibitor; or within one week of both XRT and a checkpoint inhibitor.

In certain embodiments using a single administration of a sustainedrelease formulation of CpG ODN, the subject doses of CpG ODN forintratumoral and peritumoral delivery typically range from about 0.1 mgto about 250 mg per administration, and it is given within one week ofXRT; within one week of a checkpoint inhibitor; or within one week ofboth XRT and a checkpoint inhibitor. In certain embodiments using asingle administration of a sustained release formulation of CpG ODN, thesubject dose of CpG ODN for intratumoral and peritumoral deliverytypically ranges from about 1 mg to about 250 mg per administration, andit is given within one week of XRT; within one week of a checkpointinhibitor; or within one week of both XRT and a checkpoint inhibitor. Incertain embodiments using a single administration of a sustained releaseformulation of CpG ODN, the subject dose of CpG ODN for intratumoral andperitumoral delivery typically ranges from about 10 mg to about 250 mgper administration, and it is given within one week of XRT; within oneweek of a checkpoint inhibitor; or within one week of both XRT and acheckpoint inhibitor. In certain embodiments using a singleadministration of a sustained release formulation of CpG ODN, thesubject dose of CpG ODN for intratumoral and peritumoral deliverytypically ranges from about 100 mg to about 250 mg per administration,and it is given within one week of XRT; within one week of a checkpointinhibitor; or within one week of both XRT and a checkpoint inhibitor.

In certain embodiments using a single administration of a sustainedrelease formulation of CpG ODN, the subject dose of CpG ODN forintratumoral and peritumoral delivery typically ranges from about 0.1 mgto about 100 mg per administration, and it is given within one week ofXRT; within one week of a checkpoint inhibitor; or within one week ofboth XRT and a checkpoint inhibitor. In certain embodiments using asingle administration of a sustained release formulation of CpG ODN, thesubject dose of CpG ODN for intratumoral and peritumoral deliverytypically ranges from about 1 mg to about 100 mg per administration, andit is given within one week of XRT; within one week of a checkpointinhibitor; or within one week of both XRT and a checkpoint inhibitor. Incertain embodiments using a single administration of a sustained releaseformulation of CpG ODN, the subject dose of CpG ODN for intratumoral andperitumoral delivery typically ranges from about 10 mg to about 100 mgper administration, and it is given within one week of XRT; within oneweek of a checkpoint inhibitor; or within one week of both XRT and acheckpoint inhibitor.

The desired clinical effect of the administered dose of CpG ODN canreadily be followed using standard assays and methods well known tothose skilled in the art. For example, biomarker responses to TLR9stimulation can be measured as described elsewhere herein.

CPI Antibody Dosing

Certain commercially available anti-PD-1 antibodies are currentlyapproved in the United States for intravenous infusion dosing at 2 mg/kgbody weight once every three weeks. Other commercially availableanti-PD-1 antibodies are currently approved in the United States forintravenous infusion dosing at 3 mg/kg body weight once every two weeks.Commercially available anti-CTLA-4 antibodies are currently approved inthe United States for intravenous infusion dosing at 3 mg/kg body weightonce every three weeks.

In accordance with the methods of the present disclosure, in certainembodiments, CPI antibody is administered, at least in part,systemically, e.g., intravenously.

Exemplary, non-limiting doses for a therapeutically effective amount ofa CPI antibody systemically administered according to the invention are:at least about 0.1 mg/kg body weight, at least about 0.3 mg/kg bodyweight, at least about 0.5 mg/kg body weight, at least about 1 mg/kgbody weight, at least about 2 mg/kg body weight, at least about 3 mg/kgbody weight, at least about 4 mg/kg body weight, at least about 5 mg/kgbody weight, and at least about 6 mg/kg body weight.

In certain embodiments, a therapeutically effective amount ofsystemically administered CPI antibody can range from about 0.1 to about30 mg/kg body weight, about 0.3 to about 25 mg/kg body weight, about 1to about 20 mg/kg body weight, about 2 to about 20 mg/kg body weight,about 3 to about 20 mg/kg body weight, about 5 to about 20 mg/kg bodyweight, about 10 to about 20 mg/kg body weight, about 1 to about 15mg/kg body weight, about 2 to about 15 mg/kg body weight, about 3 toabout 15 mg/kg body weight, about 5 to about 15 mg/kg body weight, about10 to about 15 mg/kg body weight, about 1 to about 10 mg/kg body weight,about 2 to about 10 mg/kg body weight, about 3 to about 10 mg/kg bodyweight, or about 5 to about 10 mg/kg body weight.

In certain embodiments, the CPI antibody is systemically administered ata dose of at least about 0.3 mg/kg body weight, at least about 1 mg/kgbody weight, at least about 2 mg/kg body weight, at least about 3 mg/kgbody weight, at least about 5 mg/kg body weight, at least about 6 mg/kgbody weight, at least 10 mg/kg body weight, at least about 15 mg/kg bodyweight, or at least about 20 mg/kg body weight.

In certain embodiments, the CPI antibody is administered by intravenous(i.v.) infusion at a dose ranging from about 0.1 to about 50 mg/kg bodyweight, from about 0.3 to about 20 mg/kg body weight, from about 1 toabout 15 mg/kg body weight, from about 2 to about 15 mg/kg body weight,from about 3 to about 15 mg/kg body weight, or from about 6 to about 15mg/kg body weight.

In certain embodiments, the CPI antibody is administered in anintravenous formulation as a sterile aqueous solution containing about 5to about 20 mg/mL of CPI antibody, in an appropriate buffer system.

In accordance with the methods of the present disclosure, in certainembodiments, CPI antibody is administered, at least in part, locally tothe cancerous tumor, i.e., by intratumoral or peritumoraladministration. In certain embodiments, such local administration is bydirect injection, while in other embodiments, such administration can betopical delivery, intraperitoneal delivery for abdominal tumors such asovarian, pancreatic, intraocular delivery for eye malignancies, oraldelivery for gastric and intestinal cancer, and intravesicularadministration for bladder cancer. Also contemplated for intratumoraladministration of CPI antibody is systemic delivery using tumor deliveryvehicles such as tumor-targeted aptamers, nanoparticles, ISCOMS, VLP,and cationic peptides.

For local, i.e., intratumoral or peritumoral, administration, the CPIantibody advantageously can be administered at a dose about 10-fold lessto about 20-fold less than the systemic doses just listed above.

In accordance with the present disclosure, CPI antibody dosing willtypically be less frequent than CpG ODN dosing. For example, anti-PD-1antibody may be administered about once every three weeks to about onceevery three months. Similarly, anti-PD-L1 antibody may be administeredabout once every three weeks to about once every three months.Similarly, anti-CTLA-4 antibody may be administered about once everythree weeks to about once every three months. The invention furtherspecifically contemplates CPI antibody dosing that is more frequent thanabout once every three weeks and less frequent than about once everythree months.

Intratumoral or peritumoral CpG and systemic CPI can be given on thesame or different days. For example, intratumoral or peritumoral CpG andthe intravenous anti-PD-1 or anti-PD-L1 can be given on the same ordifferent days.

Further, an exemplary dose escalation protocol with respect to CpG ODN,CPI antibody, or both CpG ODN and CPI antibody can be used to determinethe maximum tolerated dose (MTD), to assess dose-limiting toxicity(DLT), if any, associated with administration of CpG ODN-CPI antibodycombination therapy. For example, with respect to CPI antibody doseescalation at a given dose of CpG ODN, such protocol can compriseadministering increasing doses, such as, but not limited to about 0.1mg/kg, 0.3 mg/kg, 1 mg/kg, 2 mg/kg, 3 mg/kg, 4 mg/kg, 5 mg/kg, 6 mg/kg,7 mg/kg, 10 mg/kg, 12 mg/kg, 15 mg/kg, or more than 15 mg/kg, or anycombination thereof, more preferably, successive doses of 0.1 mg/kg, 0.3mg/kg, 1 mg/kg, 2 mg/kg, 3 mg/kg, 6 mg/kg, 10 mg/kg, 15 mg/kg or 20mg/kg are administered and the patient is assessed for toxicity, if any,as well as for efficacy of treatment, among other parameters. Suchstudies to determine toxicity and efficacy of dose regimens arewell-known in the art. See, for example, Millward M. et al., Br. J.Cancer 2013 108(10):1998-2004.

VII. Pharmaceutical Compositions

In certain embodiments, the CpG ODN is formulated with a marker, e.g., aradio-opaque marker or dye, that facilitates visualization of the CpGODN administration into and/or adjacent to the tumor to be treated.Alternatively the CpG ODN is covalently conjugated to or otherwiselabeled with a compound that enables the detection of the area ofadministration. Examples of such labels are well known in the art, andinclude fluorescent dyes, aptamers, fluorescent RNAs such as spinach andderivatives thereof, quantum dots, gold and other nanoparticles,antibodies, etc.

CpG ODN may be directly administered to the subject or may beadministered in conjunction with a nucleic acid delivery complex. Anucleic acid delivery complex shall mean a nucleic acid moleculeassociated with (e.g., ionically or covalently bound to; or encapsulatedwithin) a targeting means (e.g., a molecule that results in higheraffinity binding to target cell. Examples of nucleic acid deliverycomplexes include oligonucleotides associated with a sterol (e.g.cholesterol), a lipid (e.g., a cationic lipid, virosome, or liposome),or a target cell-specific binding agent (e.g., a ligand recognized bytarget cell specific receptor). Preferred complexes may be sufficientlystable in vivo to prevent significant uncoupling prior tointernalization by the target cell. However, the complex can becleavable under appropriate conditions within the cell so that thenucleic acid is released in a functional form.

Delivery vehicles or delivery devices for delivering oligonucleotidesand/or antigens to surfaces have been described. The CpG ODN and/or theantigen and/or other therapeutics may be administered alone (e.g., insaline or buffer) or using any delivery vehicles known in the art. Forinstance the following delivery vehicles have been described:Cochleates; Emulsomes, ISCOMs; Liposomes; Live bacterial vectors (e.g.,Salmonella, Escherichia coli, Bacillus Calmette-Guerin, Shigella,Lactobacillus); Live viral vectors (e.g., Vaccinia, adenovirus, HerpesSimplex); Microspheres; Oligonucleotide vaccines; Polymers; Polymerrings; Proteosomes; Sodium Fluoride; Transgenic plants; Virosomes;Virus-like particles, and cationic lipids, peptides, or other carriersthat have a charge interaction with the polyanionic oligonucleotide.Other delivery vehicles are known in the art and some additionalexamples are provided below in the discussion of vectors.

In one embodiment, the CPI is administered parenterally (e.g.,intravenously) in an aqueous solution while the CpG ODN is administeredby intratumoral or peritumoral injection. Preferred formulations anddosage forms of the CpG ODN are described in U.S. Patent ApplicationPublication No. US 2004/0198680, the disclosure of which is incorporatedherein by reference in its entirety. However, the skilled artisan wouldunderstand, based upon the disclosure provided herein, that theinvention is not limited to these, or any other, formulations, doses,routes of administration, and the like. Thus, the following discussiondescribes various formulations for practicing the methods of theinvention comprising administration of any CPI antibody in combinationwith a CpG ODN, but the invention is not limited to these formulations,but comprises any formulation as can be readily determined by oneskilled in the art once armed with the teachings provided herein for usein the methods of the invention.

The antibodies employed in the invention can be incorporated intopharmaceutical compositions suitable for administration to a subject.Typically, the pharmaceutical composition comprises the antibody and apharmaceutically acceptable carrier. As used herein, “pharmaceuticallyacceptable carrier” includes any and all solvents, dispersion media,coatings, antibacterial and antifungal agents, isotonic and absorptiondelaying agents, and the like that are physiologically compatible.Examples of pharmaceutically acceptable carriers include one or more ofwater, saline, phosphate buffered saline, dextrose, trehalose, glycerol,ethanol and the like, as well as combinations thereof. In many cases, itwill be preferable to include isotonic agents, for example, sugars,polyalcohols such as mannitol, sorbitol, or sodium chloride in thecomposition. Pharmaceutically acceptable substances such as wetting orminor amounts of auxiliary substances such as wetting or emulsifyingagents, preservatives or buffers, which enhance the shelf life oreffectiveness of the antibody or antibody portion.

The antibodies may be in a variety of forms. These include, for example,liquid, semi solid and solid dosage forms, such as liquid solutions(e.g., injectable and infusible solutions), dispersions or suspensions,tablets, pills, powders, liposomes and suppositories. The preferred formdepends on the intended mode of administration and therapeuticapplication. Typical preferred compositions are in the form ofinjectable or infusible solutions, such as compositions similar to thoseused for passive immunization of humans with other antibodies. Thepreferred mode of administration is parenteral (e.g., intravenous,subcutaneous, intraperitoneal, intramuscular). In a preferredembodiment, the antibody is administered by intravenous infusion orinjection. In another preferred embodiment, the antibody is administeredby intramuscular or subcutaneous injection.

Therapeutic compositions typically must be sterile and stable under theconditions of manufacture and storage. The composition can be formulatedas a solution, microemulsion, dispersion, liposome, or other orderedstructure suitable to high drug concentration. Sterile injectablesolutions can be prepared by incorporating the antibody in the requiredamount in an appropriate solvent with one or a combination ofingredients enumerated above, as required, followed by filtersterilization. Generally, dispersions are prepared by incorporating theactive compound into a sterile vehicle that contains a basic dispersionmedium and the required other ingredients from those enumerated above.In the case of sterile powders for the preparation of sterile injectablesolutions, the preferred methods of preparation are vacuum drying andfreeze drying that yields a powder of the active ingredient plus anyadditional desired ingredient from a previously sterile filteredsolution thereof. The proper fluidity of a solution can be maintained,for example, by the use of a coating such as lecithin, by themaintenance of the required particle size in the case of dispersion andby the use of surfactants. Prolonged absorption of injectablecompositions can be brought about by including in the composition anagent that delays absorption, for example, monostearate salts andgelatin.

The CpG ODN can be administered by a variety of methods known in theart, including, without limitation, local injection or infusion intoand/or adjacent to a tumor. As used herein, “into a tumor” or“intratumoral” means anywhere generally within the margins of a tumor.As used herein, “adjacent to a tumor” or “peritumoral” means anywheregenerally within about a 2.5 cm thick zone surrounding the margins of atumor. The invention also contemplates local injection or infusion ofthe CpG ODN into and/or adjacent to a tumor bed following surgicalresection of a tumor. Non-needle injection may be employed, if desired.In certain embodiments the CpG ODN can be administered locally to lungby inhalation or bronchoalveolar lavage. As will be appreciated by theskilled artisan, the route and/or mode of administration will varydepending upon the desired results.

The CPI can be administered by a variety of methods known in the art,including, without limitation, oral, parenteral, mucosal, by-inhalation,topical, buccal, nasal, and rectal. For certain therapeuticapplications, the preferred route/mode of administration issubcutaneous, intramuscular, intravenous or infusion. Non-needleinjection may be employed, if desired. As will be appreciated by theskilled artisan, the route and/or mode of administration will varydepending upon the desired results.

Dosage regimens may be adjusted to provide the optimum desired response.For example, a single bolus may be administered, several divided dosesmay be administered over time, or the dose may be proportionally reducedor increased as indicated by the exigencies of the therapeuticsituation. It is especially advantageous to formulate parenteralcompositions in dosage unit form for ease of administration anduniformity of dosage. Dosage unit form as used herein refers tophysically discrete units suited as unitary dosages for the mammaliansubjects to be treated; each unit containing a predetermined quantity ofactive compound calculated to produce the desired therapeutic effect inassociation with the required pharmaceutical carrier. The specificationfor the dosage unit forms of the invention are dictated by and directlydependent on (a) the unique characteristics of the antibody and theparticular therapeutic or prophylactic effect to be achieved, and (b)the limitations inherent in the art of compounding such an activecompound for the treatment of sensitivity in individuals.

It is to be noted that dosage values may vary with the type and severityof the condition to be alleviated, and may include single or multipledoses. It is to be further understood that for any particular subject,specific dosage regimens may be adjusted over time according to theindividual need and the professional judgment of the personadministering or supervising the administration of the compositions, andthat dosage ranges set forth herein are exemplary only and are notintended to limit the scope or practice of the claimed composition.

In one embodiment, the antibody is administered in an intravenousformulation as a sterile aqueous solution containing 5 or 10 mg/mL ofantibody, with sodium acetate, polysorbate 80, and sodium chloride at apH ranging from about 5 to 6. Preferably, the intravenous formulation isa sterile aqueous solution containing 5 or 10 mg/mL of antibody, with 20mM sodium acetate, 0.2 mg/ml polysorbate 80, and 140 mM sodium chlorideat pH 5.5.

In one embodiment, part of the dose is administered by an intravenousbolus and the rest by infusion of the antibody formulation. For example,a 0.01 mg/kg intravenous injection of the antibody may be given as abolus, and the rest of a predetermined antibody dose may be administeredby intravenous injection. A predetermined dose of the antibody may beadministered, for example, over a period of an hour and a half to twohours to five hours.

The formulations of the pharmaceutical compositions described herein maybe prepared by any method known or hereafter developed in the art ofpharmacology. In general, such preparatory methods include the step ofbringing the active ingredient into association with a carrier or one ormore other accessory ingredients, and then, if necessary or desirable,shaping or packaging the product into a desired single- or multi-doseunit.

A pharmaceutical composition of the invention may be prepared, packaged,or sold in bulk, as a single unit dose, or as a plurality of single unitdoses. As used herein, a “unit dose” is discrete amount of thepharmaceutical composition comprising a predetermined amount of theactive ingredient. The amount of the active ingredient is generallyequal to the dosage of the active ingredient which would be administeredto a subject or a convenient fraction of such a dosage such as, forexample, one-half or one-third of such a dosage.

The relative amounts of the active ingredient, the pharmaceuticallyacceptable carrier, and any additional ingredients in a pharmaceuticalcomposition of the invention will vary, depending upon the identity,size, and condition of the subject treated and further depending uponthe route by which the composition is to be administered. By way ofexample, the composition may comprise between 0.1% and 100% (w/w) activeingredient.

In addition to the active ingredient, a pharmaceutical composition ofthe invention may further comprise one or more additionalpharmaceutically active agents. Particularly contemplated additionalagents include anti-emetics, anti-diarrheals, chemotherapeutic agents,cytokines, and the like.

Controlled- or sustained-release formulations of a pharmaceuticalcomposition of the invention may be made using conventional technology.

As used herein, “parenteral administration” of a pharmaceuticalcomposition includes any route of administration characterized byphysical breaching of a tissue of a subject and administration of thepharmaceutical composition through the breach in the tissue. Parenteraladministration thus includes, but is not limited to, administration of apharmaceutical composition by injection of the composition, byapplication of the composition through a surgical incision, byapplication of the composition through a tissue-penetrating non-surgicalwound, and the like. In particular, parenteral administration iscontemplated to include, but is not limited to, intravenous,intraperitoneal, intramuscular, subcutaneous, intracisternal, and kidneydialytic infusion techniques.

Formulations of a pharmaceutical composition suitable for parenteraladministration comprise the active ingredient combined with apharmaceutically acceptable carrier, such as sterile water or sterileisotonic saline. Such formulations may be prepared, packaged, or sold ina form suitable for bolus administration or for continuousadministration. Injectable formulations may be prepared, packaged, orsold in unit dosage form, such as in ampules or in multi-dose containerscontaining a preservative. Formulations for parenteral administrationinclude, but are not limited to, suspensions, solutions, emulsions inoily or aqueous vehicles, pastes, and implantable sustained-release orbiodegradable formulations as discussed below. Such formulations mayfurther comprise one or more additional ingredients including, but notlimited to, suspending, stabilizing, or dispersing agents. In oneembodiment of a formulation for parenteral administration, the activeingredient is provided in dry (e.g., powder or granular) form forreconstitution with a suitable vehicle (e.g., sterile pyrogen-freewater) prior to parenteral administration of the reconstitutedcomposition.

A composition of the present disclosure can be administered by a varietyof methods known in the art. The route and/or mode of administrationvary depending upon the desired results. The active compounds can beprepared with carriers that protect the compound against rapid release,such as a controlled release formulation, including implants,transdermal patches, and microencapsulated delivery systems.Biodegradable, biocompatible polymers can be used, such as ethylenevinyl acetate, polyanhydrides, polyglycolic acid, collagen,polyorthoesters, and polylactic acid. Many methods for the preparationof such formulations are described by e.g., Sustained and ControlledRelease Drug Delivery Systems, J. R. Robinson, ed., Marcel Dekker, Inc.,New York, (1978). Pharmaceutical compositions are preferablymanufactured under GMP conditions.

The pharmaceutical compositions may be prepared, packaged, or sold inthe form of a sterile injectable aqueous or oily suspension or solution.This suspension or solution may be formulated according to the knownart, and may comprise, in addition to the active ingredient, additionalingredients such as the dispersing agents, wetting agents, or suspendingagents described herein. Such sterile injectable formulations may beprepared using a non-toxic parenterally-acceptable diluent or solvent,such as water or 1,3-butane diol, for example. Other acceptable diluentsand solvents include, but are not limited to, Ringer's solution,isotonic sodium chloride solution, and fixed oils such as syntheticmono- or di-glycerides. Other parentally-administrable formulationswhich are useful include those which comprise the active ingredient inmicrocrystalline form, in a liposomal preparation, or as a component ofa biodegradable polymer system. Compositions for sustained release orimplantation may comprise pharmaceutically acceptable polymeric orhydrophobic materials such as an emulsion, an ion exchange resin, asparingly soluble polymer, or a sparingly soluble salt.

The CpG ODN and CPI active ingredient components of the invention can beadministered to an animal, preferably a mammal, more preferably a human.The precise dosage administered of each active ingredient will varydepending upon any number of factors, including but not limited to, thetype of animal and type of disease state being treated, the age of theanimal and the route(s) of administration.

The CpG ODN and CPI active ingredient components of the invention may beco-administered with any of numerous other compounds (antihormonaltherapy agents, cytokines, anti-cytokine antibodies, or anti-cytokinereceptor antibodies, inhibitors of indoleamine 2,3-dioxygenase (IDO) ortryptophan 2,3-dioxygenase (TDO), chemotherapeutic, antibiotic and/orantiviral drugs, among many others). Alternatively, such othercompound(s) may be administered an hour, a day, a week, a month, or evenmore, in advance of the CpG ODN—CPI combination, or any permutationthereof. Further, such other compound(s) may be administered an hour, aday, a week, or even more, after administration of radiation, stem celltransplant, or administration of any therapeutic agent (e.g., cytokine,chemotherapeutic compound, and the like), or any permutation thereof.The frequency and administration regimen will be readily apparent to theskilled artisan and will depend upon any number of factors such as, butnot limited to, the type and severity of the disease being treated, theage and health status of the animal, the identity of the compound orcompounds being administered, the route of administration of the variouscompounds, and the like. Several instructive examples demonstratingmethods of co-administering CpG ODN—CPI combination to treat cancer areprovided, but the invention is not limited in any way to these examples,which merely serve to illustrate methods encompassed by the invention.

VIII. Kits

The invention includes various kits for treatment of cancer. The kitscomprise a therapeutically effective amount of CpG ODN and, optionally,a therapeutically effective amount of a CPI, along with instructionalmaterials which describe use of the combination to perform the methodsof the invention. In certain embodiments, the kits comprise atherapeutically effective amount of CpG ODN and, optionally, atherapeutically effective amount of a CPI antibody, along withinstructional materials which describe use of the combination to performthe methods of the invention. Although exemplary kits are describedbelow, the contents of other useful kits will be apparent to the skilledartisan in light of the present disclosure. Each of these kits isincluded within the invention.

In one embodiment, the invention encompasses a kit comprising anycombination of CpG ODN and an anti-PD-1 antibody. While such kit ispreferred, the invention is not limited to this particular combination.Further, the kit can comprise a wide plethora of additional agents fortreatment of cancer. Such agents are set forth previously and includechemotherapeutic compounds, cancer vaccines, TLR agonists other than aCpG ODN, other CpG ODNs, receptor tyrosine kinase inhibitors (such as,but not limited to, SU11248), agents useful in treating abnormal cellgrowth or cancer, antibodies or other ligands that inhibit tumor growthby binding to IGF-1R, a chemotherapeutic agent (taxane, vinca alkaloid,platinum compound, intercalating antibiotics, among many others), andcytokines, among many others, as well as palliative agents to treat,e.g., any toxicities that arise during treatment such as, but notlimited to, an anti-diarrheal, an anti-emetic, and the like.

In one embodiment, the invention encompasses a kit comprising anycombination of CpG ODN and an anti-PD-L1 antibody. While such kit ispreferred, the invention is not limited to this particular combination.Further, the kit can comprise a wide plethora of additional agents fortreatment of cancer. Such agents are set forth previously and includechemotherapeutic compounds, cancer vaccines, TLR agonists other than aCpG ODN, other CpG ODNs, receptor tyrosine kinase inhibitors (such as,but not limited to, SU11248), agents useful in treating abnormal cellgrowth or cancer, antibodies or other ligands that inhibit tumor growthby binding to IGF-1R, a chemotherapeutic agent (taxane, vinca alkaloid,platinum compound, intercalating antibiotics, among many others), andcytokines, among many others, as well as palliative agents to treat,e.g., any toxicities that arise during treatment such as, but notlimited to, an anti-diarrheal, an anti-emetic, and the like.

In one embodiment, the invention encompasses a kit comprising anycombination of CpG ODN and an anti-CTLA-4 antibody. In one embodimentthe kit is used for both agents to be administered together via anintratumoral or peritumoral route, weekly for a course of therapy. Whenthe anti-CTLA-4 antibody is delivered by intratumoral or peritumoraladministration instead of systemic, the dose will be adjusted asfamiliar to those skilled in the art: preferred doses of intratumoralanti-CTLA-4 antibody are given as a fixed dose, generally in the rangefrom 0.1 mg to 10 mg, and most preferably in the range from 1 mg to 5mg. A course of therapy may vary in duration as is standard in the art,but will typically be at least 12 weeks in duration. As long as patientsdo not develop serious toxicity, and continue to have measurable tumor,the treatment can be continued, even for a period of several years. Drugholidays and breaks from treatment are encompassed as well. Breaks intreatment may be 1 week, 2 weeks, or longer, and may be provided everymonth, or less often, or provided depending on patient tolerability.While such kit is preferred, the invention is not limited to thisparticular combination. Further, the kit can comprise a wide plethora ofadditional agents for treatment of cancer. Such agents are set forthpreviously and include chemotherapeutic compounds, cancer vaccines, TLRagonists other than a CpG ODN, other CpG ODNs, receptor tyrosine kinaseinhibitors (such as, but not limited to, SU11248), agents useful intreating abnormal cell growth or cancer, antibodies or other ligandsthat inhibit tumor growth by binding to IGF-1R, a chemotherapeutic agent(taxane, vinca alkaloid, platinum compound, intercalating antibiotics,among many others), and cytokines, among many others, as well aspalliative agents to treat, e.g., any toxicities that arise duringtreatment such as, but not limited to, an anti-diarrheal, ananti-emetic, and the like.

Having now described the present disclosure in detail, the same will bemore clearly understood by reference to the following examples, whichare included herewith for purposes of illustration only and are notintended to be limiting of the invention.

EXAMPLES Example 1—Exemplary CpG to Induce Maximal Level of Type I IFNand Minimal Level of IL-10

As described in detail in PCT/US2015/067269, examples of preferredA-class CpG ODN are:

(SEQ ID NO: 80) ggGGGACGAGCTCGTCgggggG; (SEQ ID NO: 58)ggGGGACGATCGTCGgggggG; (SEQ ID NO: 81) ggGGACGATCGAACGTgggggG;(SEQ ID NO: 78) ggGGTCGACGTCGACGTCGAGgggggG; and (SEQ ID NO: 79)ggGGACGACGTCGTGgggggG,where each lower case letter represents a nucleotide linked to its3′-adjacent nucleotide by a phosphorothioate (PS) linkage; and eachupper case letter represents a nucleotide linked to its 3′-adjacentnucleotide (if present) by a phosphodiester (PO) linkage, except thatthe 3′-terminal nucleotide is represented by an upper case letter sinceit has no 3′-adjacent nucleotide.

Examples of preferred novel A-class CpG  ODN sequences are:(SEQ ID NO:502) gGGGACGATCGTCGgggG; (SEQ ID NO:503)ggGGTCGACGTACGTCGAggggG; (SEQ ID NO: 504) gGGGTCGTCGACGAggggG;(SEQ ID NO: 505) ggGGACGAGCTCGTCgggggG; (SEQ ID NO: 506)ggGGGACGAGCTCGTCggggG; (SEQ ID NO: 507) gGGGACGAGCTCGTCggggG;(SEQ ID NO: 508) gGGGACGAGCTCGTCgggG; (SEQ ID NO: 77)ggGGACGATCGTCGgggggG; (SEQ ID NO: 49) ggGGGACGATCGTCGggggG;(SEQ ID NO: 509) gGGGACGATCGTCGggggG; (SEQ ID NO: 502)gGGGACGATCGTCGgggG; (SEQ ID NO: 81) gGGGACGATCGAACGTgggggG;(SEQ ID NO: 510) ggGGACGATCGAACGTggggG; (SEQ ID NO: 510)gGGGACGATCGAACGTggggG; (SEQ ID NO: 511) gGGGACGATCGAACGTgggG;(SEQ ID NO: 78) gGGGTCGACGTCGACGTCGAGgggggG; (SEQ ID NO: 512)ggGGTCGACGTCGACGTCGAGggggG; (SEQ ID NO: 512) gGGGTCGACGTCGACGTCGAGggggG;(SEQ ID NO: 513) gGGGTCGACGTCGACGTCGAGgggG; (SEQ ID NO: 514)gGGGACGACGTCGTGgggGG; (SEQ ID NO: 79) gGGGACGACGTCGTGgggggG;(SEQ ID NO: 514) ggGGACGACGTCGTGggggG; (SEQ ID NO: 514)gGGGACGACGTCGTGggggG; (SEQ ID NO: 515) gGGGACGACGTCGTGgggG; and(SEQ ID NO: 516) ggGTCGTCGACGAggggG,where again each lower case letter represents a nucleotide linked to its3′-adjacent nucleotide by a phosphorothioate (PS) linkage; and eachupper case letter represents a nucleotide linked to its 3′-adjacentnucleotide (if present) by a phosphodiester (PO) linkage, except thatthe 3′-terminal nucleotide is represented by an upper case letter sinceit has no 3′-adjacent nucleotide.

Examples of preferred novel A/E-class CpG ODN sequences are:

(SEQ ID NO: 1) gGGGACGAICGTCGgggG; (SEQ ID NO: 2) gGGGACGAIATCGTCggggG;(SEQ ID NO: 3) gGGGACGAGCIGCTCggggG; (SEQ ID NO: 4) ggGGICACCGGTGAggggG;(SEQ ID NO: 5) ggGGICGACGTACGTCGAggggG; (SEQ ID NO: 6)ggGGICGACGIACGTCGAggggG; (SEQ ID NO: 7) ggGGICGACGTACGICGAggggG;(SEQ ID NO: 8) ggGGICGACGIACGICGAggggG; (SEQ ID NO: 9)ggGGACGICGACGTgggG; (SEQ ID NO: 10) ggGGICGACGTCGACGTCGAGggggG;(SEQ ID NO: 11) ggGGICGACGICGACGTCGAGggggG; (SEQ ID NO: 12)ggGGICGACGTCGACGICGAGggggG; (SEQ ID NO: 13) ggGGICGACGICGACGICGAGggggG;(SEQ ID NO: 14) gGGGACGACGICGIGgggGG; (SEQ ID NO: 15)gGGGICGTCGACGAggggG; (SEQ ID NO: 16) gGGGTCGICGACGAggggG;(SEQ ID NO: 17) gGGGICGICGACGAggggG; (SEQ ID NO: 18)ggGGACGAGCICGTCgggggG; (SEQ ID NO: 19) ggGGGACGAGCICGTCggggG;(SEQ ID NO: 20) gGGGACGAGCICGTCggggG; (SEQ ID NO: 21)gGGGACGAGCICGTCgggG; (SEQ ID NO: 22) ggGGACGAICGTCGgggggG;(SEQ ID NO: 23) ggGGGACGAICGTCGggggG; (SEQ ID NO: 24)gGGGACGAICGTCGggggG; (SEQ ID NO: 1) gGGGACGAICGTCGgggG; (SEQ ID NO: 25)ggGGACGAICGICGgggggG; (SEQ ID NO: 26) ggGGGACGAICGICGggggG;(SEQ ID NO: 27) gGGGACGAICGICGggggG; (SEQ ID NO: 28) gGGGACGAICGICGgggG;(SEQ ID NO: 29) gGGGACGAICGAACGTgggggG; (SEQ ID NO: 30)ggGGACGAICGAACGTggggG; (SEQ ID NO: 30) gGGGACGAICGAACGTggggG;(SEQ ID NO: 31) gGGGACGAICGAACGTgggG; (SEQ ID NO: 32)gGGGACGAICGAACGIgggggG; (SEQ ID NO: 33) ggGGACGAICGAACGIggggG;(SEQ ID NO: 33) gGGGACGAICGAACGIggggG; (SEQ ID NO: 34)gGGGACGAICGAACGIgggG; (SEQ ID NO: 35) gGGGICGACGTCGACGTCGAGgggggG;(SEQ ID NO: 10) ggGGICGACGTCGACGTCGAGggggG; (SEQ ID NO: 10)gGGGICGACGTCGACGTCGAGggggG; (SEQ ID NO: 36) gGGGICGACGTCGACGTCGAGgggG;(SEQ ID NO: 37) gGGGICGACGICGACGTCGAGgggggG; (SEQ ID NO: 11)ggGGICGACGICGACGTCGAGggggG; (SEQ ID NO: 11) gGGGICGACGICGACGTCGAGggggG;(SEQ ID NO: 38) gGGGICGACGICGACGTCGAGgggG; (SEQ ID NO: 39)gGGGICGACGTCGACGICGAGgggggG; (SEQ ID NO: 12) ggGGICGACGTCGACGICGAGggggG;(SEQ ID NO: 12) gGGGICGACGTCGACGICGAGggggG; (SEQ ID NO: 40)gGGGICGACGTCGACGICGAGgggG; (SEQ ID NO: 41) gGGGICGACGICGACGICGAGgggggG;(SEQ ID NO: 13) ggGGICGACGICGACGICGAGggggG; (SEQ ID NO: 13)gGGGICGACGICGACGICGAGggggG; and (SEQ ID NO: 42)gGGGICGACGICGACGICGAGgggG,where “I” represents 5-iodo-2′-deoxyuridine; each lower case letterrepresents a nucleotide linked to its 3′-adjacent nucleotide by aphosphorothioate (PS) linkage; and each upper case letter represents anucleotide linked to its 3′-adjacent nucleotide (if present) by aphosphodiester (PO) linkage, except that the 3′-terminal nucleotide isrepresented by an upper case letter since it has no 3′-adjacentnucleotide.

The preferred CpG ODN of the present disclosure are synthesized usingstandard methods well known in the art and described above. The activityof the ODN are evaluated using in vitro dose-response assays on humanperipheral blood mononuclear cells (PBMC) for IFN-α and IL-10 secretionas described in the A-class and E-class patents (for example, U.S. Pat.No. 8,580,268, FIG. 27 for IFN-α, and U.S. Pat. No. 7,795,235, FIG. 27for IL-10). Because humans show inter-individual variation in themagnitude of the IFN-α response to TLR9 stimulation, PBMC from a minimumof 3 different individuals are tested for all cytokine, chemokine, andIFN assays. Freshly collected PBMC are strongly preferred for maximalresponsiveness—after 24 hr the magnitude of the in vitro responses toTLR9 ligation will be significantly lower. A-class CpG ODN are typicallytested on human PBMC at concentrations from approximately 0.1 μM toapproximately 10 μM. Supernatants are collected after approximately 24,48, or 72 hr and tested by enzyme-linked immunosorbent assay (ELISA) orother standard assay for amount of IFN-α (usually the assay justmeasures one or more of the many isoforms of IFN-α) and/or otherIFN-induced chemokines and cytokines.

Preferred A-class and A/E-class CpG ODN of the present disclosure inducean average of greater than 1000 pg/ml of IFN-α at the most effectiveconcentration in the assay (potency is less important in this regardthan peak efficacy), or more preferably greater than 3,000 pg/ml ofIFN-α and most preferably greater than 10,000 pg/ml of IFN-α; in anycase preferred ODN induce the production of at least greater than 10times the IFN-α induced by a positive control B-class CpG ODN.Supernatants from the same experiments are also tested for IL-10secretion using similar ELISA assays. Preferred A or A/E-class ODN ofthe present disclosure induce less than 1000 pg/ml, preferably less than300 pg/ml, and most preferably less than 100 pg/ml of IL-10 secretionunder these assay conditions.

The most preferred CpG ODN selected from these in vitro assays areevaluated in mouse tumor models, using standard systems well known inthe art. The mouse assays are not used to select the most active ODN tobe taken into human clinical trials, since the rank-order of the ODNwill differ, as a result of structural differences between mouse andhuman TLR9 and species-specific differences in the cell types expressingTLR9. For these reasons the primary selection of a lead candidate CpGODN to take into human clinical trials is based on the results from thein vitro assays using human cells.

Additional examples of preferred A-class CpG ODN described in detail inPCT/US2015/067269, are also contemplated by the present disclosure:

(SEQ ID NO: 517) ggGGGACGAGCTCGTCggggG (SEQ ID NO: 518)gGGGACGACGICGIGgggGG (SEQ ID NO: 519) tcgaacgttcgaacgttcgaacgttcgaat (SEQ ID NO: 520) mGmGmGmGACGACGTCGTGmGmGmGmGmG (SEQ ID NO: 521)GGGGACGACGTCGTGGGGGmG (SEQ ID NO: 522) GGGGACGACGTCGTGGGGGgtT(SEQ ID NO: 523) GGGGACGACGTCGTGGGGGGmUmU (SEQ ID NO: 524) TCGTCGACGA(SEQ ID NO: 525) GACGATCGTC (SEQ ID NO: 526) ACGACGTCGT (SEQ ID NO: 527)G+190G+190GGGAGCATGCCTGGGG#G+#G (SEQ ID NO: 528)GGGGGGGGACGATCGTCGGGGGGGGGG (SEQ ID NO: 529) GGGGGGGGGGGACGATCGTCGGGGGGG(SEQ ID NO: 530) GGGGGGGGACGATCGTCGGGGGGG (SEQ ID NO: 531)GGGGGGGGGGTCGTCGACGAGGGGGGGGGG (SEQ ID NO: 532)GGGGGGGGGGACGAGCTCGTCGGGGGGGGGG (SEQ ID NO: 533)GGGGGGGGGGACGATCGTCGGGGGGGGGG (SEQ ID NO: 534)GGGGGGGGGGTCGACGTCGACGTCGAGGGGGGGGGG (SEQ ID NO: 535)GGGGGGGGGGACGACGTCGTGGGGGGGGGG (SEQ ID NO: 536)GGGGGGGGGGAACGACGTCGTTGGGGGGGGGG (SEQ ID NO: 537)GGGGGGGGGGACGACGACGATCGTCGTCGTGGGGGGGGGG (SEQ ID NO: 538)GGGGGGGGGGCACGACGTCGTGGGGGGGGGG (SEQ ID NO: 539)GGGGGGGGGGAACGTTCGAACGTTGGGGGGGGGG (SEQ ID NO: 540)GGGGGGGGGGAACGTTCGAACGTTCGAACGTTCGAACGTTGGGGGGGG GG (SEQ ID NO: 541)GGGGGGGGGGTTCGAACGTTCGAAGGGGGGGGGG (SEQ ID NO: 542)GGGGGGGGGGACGTCGACGTCGGGGGGGGGG (SEQ ID NO: 543)GGGGGGGGGGTCGACGTCGACGGGGGGGGGG (SEQ ID NO: 544)GGGGGGGGGGACGTCGACGTACGTCGACGTGGGGGGGGGG (SEQ ID NO: 545)GGGGGGGGGGTACGATATCGTAGGGGGGGGGG (SEQ ID NO: 546)GGGGGGGGGGTACGTATACGTAGGGGGGGGGG (SEQ ID NO: 547)GGGGGGGGGGCAGCATGCTGGGGGGGGGGG (SEQ ID NO: 548) ACGACGACGA(SEQ ID NO: 549) ACGTCGACGT

Example 2—Injection Volume Effects

As used herein, CMP-001 refers to an A-class CpG-ODN, referred to as G10and SEQ ID NO: 82, that is formulated in a VLP. CMP-001 has also beenknown as CYT003 and as QbG10, under which names it has previously beenstudied in mice and humans for non-oncology indications, for example inKlimek, L., et al. “Assessment of clinical efficacy of CYT003-QbG10 inpatients with allergic rhinoconjunctivitis: a phase IIb study.” Clinical& Experimental Allergy 41.9 (2011): 1305-1312.; Casale, T. B., et al.“CYT003, a TLR9 agonist, in persistent allergic asthma—a randomizedplacebo-controlled Phase 2b study.” Allergy 70.9 (2015): 1160-1168.

There have been interesting observations in the clinic related to theeffects of different CMP-001 intratumoral (IT) injection volumes ontherapeutic response. Specifically, human clinical data show a trendtoward higher anti-tumor effect when the CMP-001 is injected in a largervolume (e.g., 5 mg dose in 5 mL has ˜40% objective response) vs. alarger dose, but smaller volume (e.g., 7.5 or 10 mg dose in 1.2 or 1.7mL volume respectively, had a 16% response rate). In addition, the serumIP-10 responses also showed a trend to the greatest fold induction atthe 5 mg (in a 5 mL volume) dose compared to the higher doses (7.5 and10 mg) that were given in a more concentrated, smaller volume (1.2 or1.7 mL respectively).

Based on these observations, preclinical studies were undertaken toexplore and more precisely document the impact of small vs. largeinjection volumes on immune activation and anti-tumor efficacy.

In order to assess the effects of injection volumes on therapeuticresponse, two studies were performed using a syngeneic A20 lymphomasubcutaneous tumor model with groups of 5 Balb/C mice. In the firststudy, mice were challenged with a single tumor, and in the second studybilateral tumors were implanted, with only one tumor per animalreceiving IT injections. Mice were treated IT with either saline (20 ulor 100 ul) or a fixed dose of 120 ug CMP-001 (30 ug CpG content)delivered in 20 uL or 100 uL (diluted with saline). All mice weretreated with a standard anti-PD-1 regimen in addition to the ITtreatments. Tumor volumes over time and survival were recorded, as wellas serum IP-10 levels 24 hrs after the first IT injection. The 5× largerinjection volume resulted in 100% and 50% higher 24 hr post treatmentIP-10 levels in the first and second studies, respectively (FIGS. 1 and3). In both studies the larger 100 ul IT injection volume resulted in ameasurable improvement in tumor growth suppression relative to the 20 ulinjection volume. The larger volume also led to a survival increase from20% to 40% in the single tumor study, and 40% to 80% in the dual tumormodel (FIGS. 2 and 4).

Example 3—Priming Dose Volume Effects

In the CMP-001-001 melanoma clinical trial, all doses are administeredIT and the initial dose level and volume are maintained for allsubsequent doses. However, in mouse studies, a single subcutaneoussmaller priming dose is generally given weeks in advance of thetherapeutic regimen in order to initiate development of antibodies tothe Qb proteins of the CMP-001 VLP. Anti-Qb antibodies are important forefficient and productive uptake of CMP-001 into the target plasmacytoiddendritic cells.

Specific, measurable volume and/or concentration dependent effectsparticular to the initial “priming” dose of CMP-001 are set out in FIG.5. Results from this study will guide the selection of priming dose(s)in additional studies designed to explore in more detail the effects ofthe therapeutic dose volume and concentration (FIG. 6).

Because volume dependent effects on systemic/lymphatic distribution ofCMP-001 may underlie the observed effects on immune activation andanti-tumor efficacy, volume dependent distribution studies with labeledCMP-001 are also designed (Figures. 5 and 7).

INCORPORATION BY REFERENCE

All patents and published patent applications mentioned in thedescription above are incorporated by reference herein in theirentirety.

EQUIVALENTS

Having now fully described the present disclosure in some detail by wayof illustration and example for purposes of clarity of understanding, itwill be obvious to one of ordinary skill in the art that the same can beperformed by modifying or changing the invention within a wide andequivalent range of conditions, formulations and other parameterswithout affecting the scope of the invention or any specific embodimentthereof, and that such modifications or changes are intended to beencompassed within the scope of the appended claims.

What is claimed:
 1. A method of treating cancer in a subject, saidmethod comprising administering at least one dose of a compositioncomprising a TLR9 agonist, wherein said composition comprising the TLR9agonist is administered in a volume of greater than 4 mL.
 2. The methodof claim 1, wherein said composition comprising the TLR9 agonist isadministered in a volume of between 5 and 20 mL.
 3. The method of claim2, wherein said composition comprising the TLR9 agonist is administeredin a volume of between 5 and 10 mL.
 4. The method of claim 1, whereinsaid composition comprising the TLR9 agonist is administered in a volumeof 5 mL.
 5. The method of claim 1, wherein said composition comprisingthe TLR9 agonist is administered in a volume of 7 mL.
 6. The method ofany of the preceding claims, wherein the TLR9 agonist induces IFN-α. 7.The method of any of the preceding claims, wherein the TLR9 agonist isCpG DNA.
 8. The method of claim 7, wherein the CpG DNA is selected fromthe group consisting of A-class CpG DNA, C-class CpG DNA, E-class CpGDNA, A/E-class CpG DNA, P-class CpG DNA, and any combination thereof. 9.The method of any of the preceding claims, wherein the TLR9 agonist isan A-class CpG DNA.
 10. The method of claim 9, wherein the wherein thesequence of the A-class CpG DNA is GGGGGGGGGGGACGATCGTCGGGGGGGGGG (SEQID NO:82).
 11. The method of any of claims 1-8, wherein the TLR9 agonistis a C-class CpG DNA.
 12. The method of any of the preceding claims,wherein the composition comprising the TLR9 agonist is formulated as avirus-like particle (VLP).
 13. The method of claim 12, wherein the TLR9agonist is an A-class CpG DNA.
 14. The method of claim 13, wherein theA-class CpG DNA formulated as a virus-like particle (VLP) is CMP-001.15. The method of any of the preceding claims, wherein the compositioncomprising the TLR9 agonist is administered via intratumoral,peritumoral, systemic, intravenous, intraperitoneal, enteric, oral,intramuscular, subcutaneous, transmucosal, topical and/or transdermalroutes.
 16. The method of claim 14, wherein the composition comprisingthe TLR9 agonist is administered intratumorally.
 17. The method of anyof the preceding claims, wherein the cancer is associated with acancerous tumor.
 18. The method of claim 17, wherein the cancerous tumoris a lymphoma or a cancerous tumor of a tissue or organ selected fromthe group consisting of skin, head and neck, esophagus, stomach, liver,colon, rectum, pancreas, lung, breast, cervix, ovary, kidney, bladder,prostate, thyroid, brain, muscle, and bone.
 19. The method of claim 18,wherein the cancerous tumor is a melanoma.
 20. The method of claim 18,wherein the cancerous tumor is a lymphoma.
 21. The method of claim 17,wherein the cancerous tumor is resistant to a treatment regimencomprising administration of a checkpoint inhibitor (CPI).
 22. Themethod of any of the preceding claims, wherein the subject is a human.23. A method of treating cancer in a subject, said method comprising (a)administering to the subject at least dose of a composition comprising aTLR9 agonist and (b) administering to the subject at least one dose of acomposition comprising a CPI, wherein the composition comprising theTLR9 agonist is administered in a volume of greater than 4 mL.
 24. Themethod of claim 23, wherein said composition comprising the TLR9 agonistis administered in a volume of between 5 and 20 mL.
 25. The method ofclaim 24, wherein said composition comprising the TLR9 agonist isadministered in a volume of between 5 and 10 mL.
 26. The method of claim23, wherein said composition comprising the TLR9 agonist is administeredin a volume of 5 mL.
 27. The method of claim 23, wherein saidcomposition comprising the TLR9 agonist is administered in a volume of 7mL.
 28. The method of any of claims 23-27, wherein the TLR9 agonistinduces IFN-α.
 29. The method of any of claims 23-28, wherein the TLR9agonist is CpG DNA.
 30. The method of claim 29, wherein the CpG DNA isselected from the group consisting of A-class CpG DNA, C-class CpG DNA,E-class CpG DNA, A/E-class CpG DNA, P-class CpG DNA, and any combinationthereof.
 31. The method of any of claims 23-30, wherein the TLR9 agonistis an A-class CpG DNA.
 32. The method of claim 31, wherein the whereinthe sequence of the A-class CpG DNA is GGGGGGGGGGGACGATCGTCGGGGGGGGGG(SEQ ID NO:82).
 33. The method of any of claims 23-30, wherein the TLR9agonist is a C-class CpG DNA.
 34. The method of any of claims 23-33,wherein the composition comprising the TLR9 agonist is formulated as avirus-like particle (VLP).
 35. The method of claim 34, wherein the TLR9agonist is an A-class CpG DNA.
 36. The method of claim 35, wherein theA-class CpG DNA formulated as a virus-like particle (VLP) is CMP-001.37. The method of any of claims 23-36, wherein the compositioncomprising the TLR9 agonist is administered via intratumoral,peritumoral, systemic, intravenous, intraperitoneal, enteric, oral,intramuscular, subcutaneous, transmucosal, topical and/or transdermalroutes.
 38. The method of claim 37, wherein the composition comprisingthe TLR9 agonist is administered intratumorally.
 39. The method of anyof claims 23-38, wherein the cancer is associated with a canceroustumor.
 40. The method of claim 39, wherein the cancerous tumor is alymphoma or a cancerous tumor of a tissue or organ selected from thegroup consisting of skin, head and neck, esophagus, stomach, liver,colon, rectum, pancreas, lung, breast, cervix, ovary, kidney, bladder,prostate, thyroid, brain, muscle, and bone.
 41. The method of claim 40,wherein the cancerous tumor is a melanoma.
 42. The method of claim 40,wherein the cancerous tumor is a lymphoma.
 43. The method of claim 39,wherein the cancerous tumor is resistant to a treatment regimencomprising administration of a checkpoint inhibitor (CPI).
 44. Themethod of any of claims 23-44, wherein the subject is a human.
 45. Themethod of any of claims 23-45 wherein the composition comprising the CPIis administered via intratumoral, peritumoral, systemic, intravenous,intraperitoneal, enteric, oral, intramuscular, subcutaneous,transmucosal, topical and/or transdermal routes.
 46. The method of claim23, wherein the CPI is an antibody or antigen-binding fragment thereofwhich binds specifically to an antigen selected from the groupconsisting of PD-1, PD-L1, and CTLA-4.
 47. The method of claim 46,wherein the CPI is an antibody or antigen-binding fragment thereof whichbinds specifically to PD-1.
 48. The method of claim 46, wherein the CPIis an antibody or antigen-binding fragment thereof which bindsspecifically to PD-L1.
 49. The method of claim 46, wherein the CPI is anantibody or antigen-binding fragment thereof which binds specifically toCTLA-4
 50. The method of claim 23, wherein the composition comprisingthe CPI comprises a combination of CPIs selected from the groupconsisting of: (a) a first antibody or antigen-binding fragment thereofwhich binds specifically to CTLA-4, and a second antibody orantigen-binding fragment thereof which binds specifically to PD-1; (b) afirst antibody or antigen-binding fragment thereof which bindsspecifically to CTLA-4, and a second antibody or antigen-bindingfragment thereof which binds specifically to PD-L1; (c) a first antibodyor antigen-binding fragment thereof which binds specifically to PD-1,and a second antibody or antigen-binding fragment thereof which bindsspecifically to PD-L1.
 51. The method of claim 23, wherein thecomposition comprising the TLR9 agonist is administered prior toadministration of the composition comprising the CPI.
 52. The method ofclaim 23, wherein the composition comprising the TLR9 agonist and thecomposition comprising the CPI are administered substantially at thesame time.
 53. The method of claim 23, wherein the compositioncomprising the TLR9 agonist and the composition comprising the CPI areadministered via different routes.
 54. The method of claim 23, whereinthe composition comprising the TLR9 agonist and the compositioncomprising the CPI are administered via the same route.
 55. The methodof claim 23, wherein at least two doses of the composition comprisingthe TLR9 agonist are administered or wherein at least two doses of thecomposition comprising the CPI are administered.
 56. The method of claim23, wherein (a) two doses; (b) three doses; (c) four doses; or (d) fivedoses of the composition comprising the TLR9 agonist are administered.57. The method of claim 23, wherein two doses of the compositioncomprising the TLR9 agonist are administered prior to administration ofthe composition comprising the CPI.
 58. The method of claim 23, whereinthe composition comprising the CPI is administered prior toadministration of the composition comprising the TLR9 agonist.
 59. Themethod of claim 23, wherein the composition comprising the TLR9 agonistand the composition comprising the CPI are administered concurrently andat least two doses of each composition are administered.
 60. The methodof claim 23, wherein the composition comprising the TLR9 agonist and thecomposition comprising the CPI are administered sequentially and atleast two doses of each composition are administered.
 61. The method ofclaim 23, wherein the composition comprising the TLR9 agonist and thecomposition comprising the CPI are administered sequentially and by thesame route.
 62. The method of claim 23, wherein the compositioncomprising the TLR9 agonist and the composition comprising the CPI areadministered sequentially and by different routes.
 63. The method ofclaim 23 where the composition comprising the TLR9 agonist isadministered 1 to 3 weeks before the composition comprising the CPI. 64.The method of claim 1 or claim 23, further comprising administering oneor more additional therapeutic agents or treatments.
 65. The method ofclaim 64 wherein the one or more additional therapeutic agents ortreatments is selected from the group consisting of an immune checkpointinhibitor, an antibody that activates a co-stimulatory pathway, a cancerchemotherapy, and radiation therapy.